
Class. 



Book 



COPYRIGHT DEPOSIT 



Frontispiece. 




A MANUAL OF 



SYPH ILIS 



VENEREAL DISEASES 



BY 

JAMES NEVINS/HYDE, A.M., M. D. 

PROFESSOR OF SKIN AND VENEREAL DISEASES, RUSH MEDICAL COLLEGE; DERMA- 
TOLOGIST TO THE PRESBYTERIAN, MICHAEL REESE, AND AUGUSTANA 
HOSPITALS; AND CONSULTING PHYSICIAN TO THE HOSPITAL 
FOR WOMEN AND CHILDREN, CHICAGO ; 



FRANK H. MONTGOMERY, M. D. 

LECTURER ON DERMATOLOGY AND GENITO-URINARY DISEASES, AND CHIEF ASSISTANT 

TO THE CLINIC FOR SKIN AND VENEREAL DISEASES. RUSH MEDICAL 

college; attending PHYSICIAN FOR SKIN AND VENEREAL 

DISEASES, ST. ELIZABETH HOSPITAL, CHICAGO. 



WITH 44 ILLUSTRATIONS IN THE TEXT 
AND 8 FULL-PAGE PLATES IN COLORS AND TINTS. 



PHILADELPHIA 
W. B. SAUNDER 

925 Walnut Street 
1895. 




f 



OlO, 



9 



A 



. V \ 



x 



Copyright, 1895, by 
W. B . SAUNDERS. 



ELECTROTYPED BY PRESS OF 

WESTCOTT &. THOMSON, PHILADA. W. B. SAUNDERS, PHILADA. 



PREFACE. 



This Manual has been prepared with the intent of 
meeting the special needs of the student and of the 
practitioner rather than of the expert. The aim has 
been to supply in a compendious form, and with detail, 
all practical facts connected with the study and the 
treatment of syphilis and the venereal diseases. Care 
has been taken to avoid all points in controversy and to 
exclude the data which are to be sought for in the more 
voluminous treatises on these subjects. 

The authors are glad to express their special obliga- 
tions to the classical works of Fournier, Jullien, and 
Mauriac ; to Keyes' exceedingly practical treatise on 
Genito-iirinary Diseases, including Syphilis ; to Morrow's 
valuable System of Genito-urinary Diseases, Syphilology, 
and Dermatology, in three volumes, and in especial to 
the carefully written chapters of that work on stricture 
of the urethra and syphilis of the eye and ear. The 
treatise of Bumstead and Taylor, which has so long and 
so well represented the advance of knowledge in vene- 
real diseases, has frequently been consulted, as has also 
the standard monograph by Finger on Blennorrhoe , and 
the excellent handbook of Messrs. Culver and Hayden. 



4 PREFACE. 

The authors of this manual are also gratified in 
acknowledging in this public manner their appreciation 
of the courtesy of Messrs. William Wood & Co. of 
New York, who kindly gave permission to reproduce 
the plates originally contributed by Dr. Hyde to their 
Reference Handbook of the Medical Sciences ; to Dr. 
Petrini of Galatz, for permission to reproduce his fine 
plate showing the micro-organism of Ducrey; to Dr. 
John A. Fordyce of New York, for his kindness in 
supplying the micro-photograph of gonococci which 
has been employed as one of the illustrations ; and to 
Messrs. Lea Bros. & Co. of Philadelphia, for permis- 
sion to make use of one of their original cuts. 

The authors are also glad to express their acknowl- 
edgments to Dr. W. F. Robinson for his efficient aid 
while these pages were passing through the press. 



CONTENTS. 



PAGE 

Introduction 17 

Syphilis 27 

Acquired Syphilis 27 

Syphilis of the Skin , , 73 

Syphilitic Affections of the Hair 133 

Syphilitic Affections of the Nail 136 

Syphilis of the Mouth and the Tongue 142 

Syphilis of the Respiratory Tract 152 

Syphilis of the Bones 159 

Syphilis of the Larger Joints ' 165 

Syphilis of the Bursse 166 

Syphilis of the Tendons and the Tendinous Sheaths ..... 166 

Syphilis of the Aponeuroses 167 

Syphilis of the Muscles 167 

Syphilis of the Heart 168 

Syphilis of the Blood-vessels 170 

Syphilis of the Lungs . 171 

Syphilis of the Gastro-intestinal Tract 173 

Syphilis of the Rectum and the Anus 175 

Syphilis of the Genito-urinary Organs 1 81 

Syphilis of the Nervous System . 187 

Syphilis of the Eye and Ocular Appendages 194 

Syphilis of the Ear 203 

Hereditary Syphilis 205 

Treatment of Syphilis 227 

Acquired Infantile Syphilis 283 

Syphilis in Relation with the Family and Society 284 

Chancroid 293 

Disorders not Invariably Venereal 331 

Balanitis and Balano-posthitis 331 

Phimosis 334 

Paraphimosis . 338 

5 



6 CONTENTS. 

PAGE 

"Venereal" Warts 342 

Herpes Progenitalis 344 

Hypochondriasis 347 

Acute Urethritis 360 

Complications of Ure'-^hritis 417 

Acute Posterior Urethritis 417 

Epididymitis 422 

Prostatitis 437 

Vesiculitis 448 

Cystitis 450 

Pyelitis 454 

Folliculitis 456 

Periurethritis 457 

Cowperitis , ■ . . 4159 

Lymphangitis 460 

Adenitis 460 

Gonorrhoeal Rheumatism 461 

Gonorrhoeal Conjunctivitis '470 

Ophthalmia Neonatorum 479 

Gonorrhoeal Inflammation of the Rectum and the Mouth .... 481 

Chronic Urethritis , 483 

Stricture of the Urethra 526 

Spasmodic Stricture of the Urethra 527 

Congenital Stricture of the Urethra 531 

Organic Stricture of the Urethra . , 534 

Instrumentation of the Urethra 553 

Gonorrhcea in Women 600 



Index 607 



LIST OF ILLUSTRATIONS. 



FIGURES. 

FIG. PAGE 

1. Palmar syphiloderm (after Keyes) 97 

2. Moist papules (after Miller) loi 

3. Large pustular syphiloderm (after Stelwagon) 107 

4. Rupia (after Tilbury Fox) , , . 109 

5. Resolutive tubercular syphiloderm in groups 1 14 

6. Serpiginous tubercular syphiloderm (after Stelwagon) n6 

7. Ulcerative tubercular syphiloderm (after Keyes) . .117 

8. Gummata (after Jullien) 121 

9. Cicatrices resulting from extensive gummatous infiltration of the 

face 124 

10. Sabre-blade deformity of the tibiae in hereditary syphilis . . . .216 

11. Hutchinson's teeth vi^ith osteo-periostitis and ulceration in inherited 

syphilis 219 

12. Phimosis from gonorrhoea (Cullerier) 335 

13. Paraphimosis (Cullerier) 338 

14. 15. Reduction of paraphimosis 340 

16. Urethral syringe 411 

17. Kiefer's urethral irrigation nozzle 497 

18. Klotz's endoscope 5°° 

19. 20. Urethral specula 501 

21. Brovi^n's method of illuminating the urethra 502 

22. W. K. Otis's "perfected" urethroscope 503 

23. Winternitz's psychrophor 5^9 

24. Keyes-Ultzmann syringe 5^9 

25. Annular stricture (Dittel) 535 

26. Tortuous stricture (Dittel) 536 

27. The normal urethra (Thompson) 554 

28. Proper and improper curves for unyielding male urethral instru- 

ments 555 

29. 30. Sounding of the urethra (Keyes) 557 

7 



8 LIST OF ILLUSTRATIONS. 

FIG. PAGE 

31. Sounding of the urethra (Keyes) 558 

32. Sounding of the urethra (Keyes) 559. 

33. Relative positions of triangular ligament and bulb of urethra (Cul- 

ver and Hayden) 561 

34. Handerson's gauge 563 

35. Bulbous bougie ' 564 

36. Otis's urethrometer 564 

37. Olivaiy gum bougie 565 

38. Mercier elbowed catheter 565 

39. Gouley's whalebone bougies 565 

40. Gouley's catheter-staff 567 

41. Gross's modification of Civiale's urethrotome 590 

42. Otis's dilating urethrotome 591 

43. Teevan's modification of Maisonneuve's urethrotome with guide . 592 

44. Suprapubic and rectal routes for the relief of retention of urine 

(redrawn from Holden) 594 

PLATES. 

PLATE 

1 . Initial sclerosis of the penis Frontispiece, 

2. Chancre and papillary growths of the tongue (Hutchin- 

son) facing page 35 

3. Small papular syphiloderm (Stelwagon) " 92 

4. Pustulo-ulcerative syphiloderm " 108 

5. Pustulo-ulcerative syphiloderm in a cachectic subject . " no 

6. Syphilitic disease of the tongue (Hutchinson) ... '* 149 

7. Fig. I. Hutchinson's teeth. Fig. 2. Bacillus of Ducrey 

(Petrini de Galatz) " 296 

8. Fig. I. Gonococci in gonorrhoeal pus (Fordyce). Fig. 

2. Gonococcus (Bumm) " 362 



SYPHILIS 



VENEREAL DISEASES 



INTRODUCTION. 



The venereal diseases are for the most part trans- 
mitted from one individual to another in the contacts 
incident to the relations between the sexes. The day is 
long past, however, when a moral stigma could be 
affixed to the victim of such a malady by reason of the 
fact of infection. In the populous and crowded centres 
of modern civilization the innocent subjects of these dis- 
orders are numbered by hundreds and even thousands. 
They are in a special sense entitled to the encouraging 
assistance and the sympathetic service of the trained 
physician. 

The great majority of the other victims are patients 
infected at a time of life when passion is most imperi- 
ous, self-restraint less strenuously imposed, and the dis- 
cipline which unfolds the deeper meanings of life is less 
understood and appreciated. The result is twofold : on 
the one hand are patients for the most part, fortunately, 
of an age and possessed of a vigor best capable of endur- 
ing without serious shock the perils of an intoxication 
2 ir 



1 8 SYPHILIS AND THE VENEREAL DISEASES. 

of the system, and in a social state least likely to burden 
others, such as a wife or a child, with the consequences 
of disease ; on the other hand are the subjects of these 
infections, who, without fixed habits, are obliged to con- 
form to the rules of best living when actually suffering 
from their ailments, and who learn lessons which at 
their time of life are often indelible. The most radical 
of moral reforms with the best of ultimate results is con- 
stantly wrought by the several accidents described in the 
following pages. 

In the early part of this century the prejudices of the 
people of most English-speaking countries and the 
odium connected with the acquisition and inheritance 
of venereal disease extended even to the professional 
men interested in their treatment. As a consequence, 
this department of medicine was largely relegated to 
the charlatan, who, under the control of ignorance and 
avarice, contributed to the exaggeration and confusion 
which still cloud the minds of many when they consider 
the subject. 

To-day the change in these particulars is noteworthy. 
Science has solved some of the profoundest problems 
and achieved some of its most brilliant bacteriological 
and pathological victories in the territory once aban- 
doned as a plague-spot. Some of the most cultivated, 
learned, and distinguished of the physicians of the last 
quarter of the nineteenth century have been content to 
labor and to glean in the field that was thus once 
neglected and abhorred. 

It has been well for the race that these men could 
thus with untiring industry and interest investigate the 
diseases commonly described as *' loathsome." But 
many of them have paid a price for their courage. It is 



IN TR on UCTION. 1 9 

impossible to give accurate statistics of the number of 
physicians innocently infected with the venereal diseases, 
and particularly with syphilis, when engaged in the 
practice of their profession as accoucheurs, surgeons, 
gynecologists, and those giving special attention to the 
affections of the genito-urinary organs of both sexes. 
Hundreds of them have been under our observation and 
care ; thousands have thus suffered in every country. 
Only with the incessant precautions suggested by the 
later knowledge on the subject of the pathogenic micro- 
organisms can a physician hope to be successful in the 
management of these disorders and himself escape their 
defilement. Nor in his attempts to compass this end 
can he with safety rely only upon the products of 
pharmacy and the skill of the chemist. He must be, in 
his person, his instruments, and his entourage, an 
embodiment of scrupulous cleanliness. 

The disorders usually classed under the general title 
of " venereal " are syphilis, the several forms of infec- 
tious urethritis, and the soft (" simple " or " non-syphi- 
litic ") chancre. In a stricter sense of the term, and in 
the light of modern investigation, there are other dis- 
orders described in these pages capable of transmis- 
sion in the sexual act. The more important, however, 
of the group are without question those here named. 
It is probable, though exact statistics are wanting, 
that infectious urethritis is the most frequent, soft 
chancre (certainly in particular classes of society) next, 
and syphilis, in all classes, last. Further comparison 
teaches that while gonorrhoea is most often a strictly 
venereal disorder, syphilis is with greater frequency an 
affection of the innocent ; while, as respects a fatal issue, 
gonorrhoea, in its ultimate results upon the deep urethra, 



20 SYPHILIS AND THE VENEREAL DISEASES. 

the bladder, and the kidneys, probably destroys more 
lives annually than does syphilis. Gonorrhoea more 
often than syphilis spares the subjects of tender age, 
and is further capable of indefinite recurrence in one 
subject ; while for the immense majority of cases 
syphilis is a disease making but a single attack in the 
lifetime of the individual. The proposition once held 
cannot longer be sustained, that gonorrhoea and soft 
chancre are purely local diseases as contrasted with 
syphilis, which is admitted to have systemic effects. 
The generalized results of gonorrhoea are in many 
instances too striking to admit even of question ; and in 
special cases the perpetuation of the soft chancre for 
years, with the damage resulting to rectum, vulva, 
abdominal wall, and thigh, with the production of 
marked cachexia, often renders that affection one even 
of greater severity than the milder cases of syphilis. 

The questions relating to the history and antiquity of 
the venereal diseases have created a voluminous litera- 
ture, with results not wholly satisfactory. The sacred 
literature of the Hebrews seems to bear record to the 
fact that blennorrhagic affections existed among the 
people of a remote antiquity, and that the gonorrhceal 
discharge was with them confounded with a seminal 
flow. Among the writings of Greek, Roman, African, 
and Spanish authors, both medical and literary, evi- 
dences are not wanting as to the existence of such a 
disease and its occasional confusion with other disorders 
of a venereal origin. Even as early as the beginning of 
the present century, English physicians confounded 
gonorrhoea, syphilis, and non-syphilitic chancre, and it 
was reserved for a comparatively recent date to distin- 
guish definitely and finally between them. 



INTR on UCTION. 2 1 

For the remote antiquity of syphilis there are not 
wanting authors who find in the sacred writings of the 
Hebrews, in the sarcastic, poetical, and historical litera- 
tures of Greece and Rome, in the ancient documents of 
Egypt, China, and Africa, and in the volumes written 
during the Middle Ages, records among the people of 
those periods of the existence of chancres and of the 
systemic results of certain genital lesions. The evi- 
dence of bones exhumed and supposed to belong to 
a prehistoric era is also adduced in support of the 
assumed antiquity of syphilis. On the other hand, there 
are many who believe that syphilis existed among the 
American aborigines before the advent in 1492 of 
Columbus and his companions to the American coast, 
and that the Spaniards, becoming infected by contact 
with the natives, brought the disease to Europe, where 
it appeared for the first time after their return. In the 
subsequent campaign of Charles VIII. of France against 
the kingdom of Naples the disease appeared and spread 
among the nations of Europe to an extent and with a 
severity before then unknown. 

In reviewing the entire subject many of the argu- 
ments in favor of the historical antiquity of these 
diseases are, it must be admitted, weakened by the 
indefiniteness of the descriptions given. The bones 
alleged to be both prehistoric and syphilitic are either 
lacking in the display of unmistakable lesions of that 
disease or cannot conclusively be demonstrated to be 
both of prehistoric sepulture and since then wholly 
undisturbed by the hand of man. The arguments in 
favor of a prehistoric syphilis in America and of its 
subsequent deportation to Europe are weighty, but not 
without flaw. 



22 SYPHILIS AND THE VENEREAL DISEASES. 

The conclusions are simple : the evidence of a remote 
antiquity for the venereal diseases in general is very 
strong. In the absence of the definite distinctions 
between them now established, and of a recognition of 
the pathological connection between the local mani- 
festations of such diseases and their systemic effects, 
great confusion has existed in the past. Lastly, the 
venereal diseases have all, without question, been con- 
fused inextricably in the past, not merely with each 
other, but with a large number of dermatological affec- 
tions, such as lepra, psoriasis, scabies, eczema, simple 
and venereal warts, and leucorrhoeal and catarrhal 
discharges. 

In the examination of patients affected with one or 
several of the disorders here considered, a systematic 
method is of as much value as in other departments 
of medicine. Besides ascertaining the name, age, resi- 
dence, married state, occupation, and previous history 
of the patient, as well as the habits respecting the use 
of both alcohol and tobacco, it is desirable to know, for 
reasons that appear later, in the case of both man and 
woman, the record as respects living and dead children, 
miscarriages and abortions on the part of a wife, and 
the relative order of these, as well as the period in 
pregnancy when a series of abortions or miscarriages 
occurred. In securing the history of the family and of 
any antecedent disease it is necessary to record all facts 
respecting any prior disease of the skin, persistent head- 
ache, especially with nocturnal exacerbation, any attacks 
supposed to be rheumatic, and any persistent or ulcera- 
tive affection of the throat, eyes, scalp, or nails. 

In the case of venereal disease it is important to 
know whether the patient can sleep at night without 



INTRODUCTION. 23 

rising from the bed to empty the bladder; whether 
there is pain on micturition, and, in the latter event, 
whether the pain occurs before, during, or after the 
passage of the stream. 

In the physical examination of patients the several 
bodily organs should be investigated with care, the 
surface of the body, when found practicable, being 
searched for traces of any existing or past exanthem, 
and particularly for scars, each of which may throw 
light on the conditions existing. The superficial glands 
of the body accessible to the fingers should be searched 
with a view to determining any enlargement or indura- 
tion. The mouth, nostrils, eyes, and ears require 
minute observation of lesions present; and even in the 
absence of the latter the nails may exhibit markings 
indicative of the character, and at times of even the 
date, of prior nutritional changes. 

In the case of male patients the entire surface of the 
body may often be exposed for examination, and the 
genital region then requires detailed inspection. By the 
fingers and the eye the physician can usually determine 
the existence of pediculi or nits in the pubic region, an 
eczema or a psoriasis of the cutaneous surface of the 
penis or the scrotum, mollusca of the latter region, or 
the evidence of scabies. By manipulation it will be 
discovered whether there is an inguinal hernia, a non- 
descended testis, a left- or more rarely a right-sided vari- 
cocele, a gumma of the body of the testicle, or traces 
of an ancient epididymitis involving the globus minor 
or major as a sequel of a preceding blennorrhagia. By 
the fingers alone it will often be practicable to recognize 
a urethral stricture, a periurethral phlegmon, an en- 
larged prostate, a syphilitic or a chancroidal bubo, a 



24 SYPHILIS AND THE VENEREAL DISEASES. 

severe phimosis, a subpreputial sclerosis or other lesion, 
or a urethral chancre. In point of fact, a urethral 
sclerosis that cannot be recognized by the digit of the 
trained physician is among the greatest of rarities. 
Indeed, one might here enumerate the entire list of 
diseases of the ano-genital region, evidences of which 
the examining surgeon should not permit to escape his 
observant eye and trained touch. 

In all classes of women the examination should be 
made with the special consideration to which the sex is 
entitled. A follicular or furuncular affection of the 
labia, a catarrhal discharge from the vulva, a sclerosis 
of the meatus or of the fourchette, or a stellate chancroid 
of the anal region, may often be determined by inspec- 
tion alone. The physician must know to distinguish 
between a languette accompanying a syphilitic stricture 
of the rectum and a hemorrhoidal tumor. He must be 
capable of recognizing the marked differences between 
a pruritus of the vulva, which is simply tormented by 
scratching, and an eczema of the same part. By carefully 
inspecting the dry and " sticky " mouth of a woman it can 
be determined with reasonable probability, before subject- 
ing the urine to chemical analysis, that an " eczema " of 
the vulva is due simply to a glycosuria. The fingers 
should differentiate an inflammation of the vulvo-vaginal 
gland due to gonorrhoea from a syphiloma of the 
labium. Scabies of the genital region in a woman will 
usually be an echo of characteristic burrows about the 
axillae or the breasts. By the touch one should be able 
to discover a hydrocele of the canal of Nuck, a varico- 
cele, a carcinoma, an elephantiasis, a contracture of the 
vagina, a laceration, an atresia of the hymen, or a 
vaginismus. 



► 



INTR OD UCTION. 2 5 

Nor should it be concluded in either sex that a deter- 
mination of the virgin state precludes the possibility of 
venereal disease. The physician should ever be on the 
alert to recognize a chancre of the tonsil, an infecting 
sclerosis of the lip in the child who has kissed a 
syphilitic nursling, a gonorrhoea affecting the vulva or 
the eyes of an infant, a paralysis in the middle period 
of life due rather to a pachymeningitis than to an apo- 
plectic effusion. 

Lastly, the physician entrusted with an intimate 
knowledge of the sources of diseases that are viewed 
with shame, loathing, and remorse, often imperilling the 
life of the individual, the safety of the uninfected, and 
the happiness of a home, has a part to perform which 
demands a high order of intelligence and sympathy. 
His it is to protect the innocent, to guard sacredly the 
secrets confided to his keeping, to conserve the family 
relation, and at the same time to bring the sufferer to a 
successful termination of the disease. It is difficult to 
decide that any one of these functions has a higher 
importance than another. It is only as the physician 
discharges his full duty in all points that he ultimately 
wins that trust and confidence which are the foundation 
of the largest professional success. 



SYPHILIS. 



Synonyms. — Lues venerea ; Morbus gallicus ; Pox ; 
" Bad disorder ;" Fr. Verole ; lial. Sifilide ; Ger. Lust- 
seuche; Krankheiten der Franzosen ; Span. Sifilis; 
Szved. Radezyge. 

Syphilis is a general infectious disorder transmitted 
from one individual to another by both contact and 
inheritance, chronic in course, and displaying in a more 
or less determinate sequence symptoms involving one 
or several of the organs of the body. It is classed with 
the infectious granulomata, and it is due to the toxic 
effect of the invasion of the bodily tissues by a morbific 
germ. Though the identity and relations of the latter 
have not completely been established (as has been done 
in the case of the bacilli of tuberculosis and lepra), no 
doubt can be entertained as to its existence and potency. 

ACQUIRED SYPHILIS. 

Syphilis is said to be acquired when transmitted in 
another way than by inheritance. The term " contact- 
syphilis " has also been employed to distinguish the 
former from the latter. 

Btiology. — The micro-organisms which are effective 
in the production of this disease have not yet been 
incontestably demonstrated. Donne, Hallier, Lostorfer, 
Klebs, Doutrelepont, Lustgarten, Fordyce, and many 
others have repeatedly, by difficult and delicate methods 
of staining, recognized bacilli in syphilitic tissue. The 

27 



28 SYPHILIS AND THE VENEREAL DISEASES. 

failure to distinguish the exact micro-organism whose 
toxine may be efficient as a cause of the disease is due 
partly to the fewness of the bacilli present in any one 
section, to the circumstance that the bacilli found in the 
smegma praeputii are either identical with or very sim- 
ilar to the supposed syphilitic germ, and to a fact 
pointed out by Fordyce, that the general absence of 
giant-cells in syphilitic tissue forbids their use as a 
guide to the location of the bacilli. 

But if the germ of the disorder has not yet been 
distinguished satisfactorily, no doubt exists as to the 
fact that a germ-carrying secretion or virus, which may 
be collected on the point of a lancet, is capable of trans- 
mitting the disease. This virus must be furnished by a 
person infected with syphilis. 

The purveyors of this virus are usually in an early or 
active stage of the disease. They may furnish a patho- 
logical secretion, such as that supplied by a mucous 
patch, a chancre, a syphilitic pustule, or an ulcer. Such 
a secretion may be commingled with a physiological 
fluid (tears, saliva, milk), and be thus effective, however 
innocent to the view, though the physiological secre- 
tions of a syphilitic subject not thus mingled with a 
virus are rarely, if ever, noxious. The blood of such 
subjects is, however, capable of transmitting the disease. 
Pathological secretions of other character (gonorrhoeal, 
leucorrhceal, vaccinal) may readily be commingled with 
the virus of syphilis, and thus be effective in its trans- 
mission. 

The evidence as to the date when the syphilitic 
subject can no longer furnish an infectious virus is con- 
fusing. Up to a recent time it was believed that the late 
lesions of syphilis (so-called *' tertiary ") were incapable 



ACQUIRED SYPHILIS. 29 

of furnishing such a virus. Instances are, however, on 
record disproving this ; and, though the power to 
furnish a virus is gradually lost in every surviving 
subject of syphilis, it is safest to hold that any awaken- 
ing of the morbid process at a late date may, however 
rarely, render such persons dangerous to the uninfected. 

The modes of infection are both immediate and 
mediate. The direct contacts of the sexual act (includ- 
ing the perverted and unnatural imitations of the latter) 
and the opportunities of transmission afforded in kiss- 
ing, biting, sucking, etc. are often the beginnings of 
syphilis. In the same category may be named all the 
accidental contacts which occur in the service of the 
physician, the nurse, and the midwife, and those where 
prisoners are manacled together. 

The articles which have been mediately effective as 
virus-carriers are so many and so various as to forbid 
enumeration. The list includes a great number of 
household utensils (forks, cups, spoons), articles of 
domestic use (tooth-brushes, syringes, combs), articles 
employed in the professions (dentists' forceps, surgical 
instruments and appliances, razors, vaccinating needles, 
lancets), and, in brief, almost every substance brought 
into contact with the human body, from nursing-bottle 
to water-closet seat, and from the finger moistened in 
the mouth of the nurse and given to the nursling to the 
tools of the chiropodist. 

Given an infective germ in its vehicle (the virus), 
furnished by an infected subject of syphilis (in a stage 
of that disease capable of transmissibility by contact), it 
remains to inquire whether the person inoculated with 
such a virus, mediately or immediately conveyed, will 
suffer from the disease. A categorical answer to this 



30 SYPHILIS AND THE VENEREAL DISEASES. 

question cannot be given. There is reason to believe 
that all individuals are not equally susceptible to the 
action of the virus. These reasons are based on the 
accepted fact of repeated exposures of certain persons 
without evident results ; of repeated exposures with 
results that are slight, or, if threatening at first, abortive 
as to any ultimate consequences ; and of well-known 
analogies existing between this disease and others 
in which the proofs of susceptibility and non-suscepti- 
bility of individuals are irrefragable. 

All such instances are, however, exceptions to a rule 
that is enforced by constant experience. The husband 
recently infected as a result of infidelity to his wife 
communicates his disease to the latter with almost 
unfailing regularity; the lover with a mucous patch 
upon his lip gives his disorder with an appalling cer- 
tainty to the woman whom he kisses upon the mouth. 
For practical purposes it is best to assume that all men, 
women, and children are susceptible who have not been 
protected either by a previous attack of the disease or 
(a point to which attention is called later) by the 
experience of the mother who brings into the world a 
syphilitic child diseased by inheritance from the father, 
while she seems to escape. 

Chancre. 

Synonyms. — Syphilitic chancre ; Initial lesion or 
sclerosis of syphilis ; Hard chancre ; Infecting chancre ; 
Ger. Hartes Geschwiar ; Schanker; Fr. Chancre syph- 
ilitique. 

The first evidence of a successful transmission of 
syphilis from an infected to a sound person is termed a 
'* chancre," or, as this last term has often been errone- 



ACQUIRED SYPHILIS. 3 1 

ously applied to non-syphilitic local venereal disorders, 
better the " initial lesion of syphilis," 

The First Incubation. — After the successful intro- 
duction of the syphilitic virus into a sound body an 
interval occurs before the evolution of the initial lesion 
is appreciable to the eye. This interval is called the 
" period of the first incubation," a phrase suggestive of 
the ignorance of the earliest observers. It is almost 
certain that from the instant of a successful inoculation 
the subject is, however imperceptibly to human tests, 
syphilitic, and that there is, without pause or arrest, a 
multiplication of the effective germs of the disease to the 
point where the lesions produced by these germs become 
apparent to coarse methods of observation. This interval 
is by different observers made to extend over a period of 
time with singularly varying limits. The average is 
between twenty-one and twenty-six days, but the period 
has been claimed to be as brief as from one to two 
days and as extended as three months. The numerous 
chances of error in all these estimates need not be pointed 
out. Between ten and thirty days after infection the vast 
majority of all infecting chancres appear. The reverse 
is also true : on the first appearance of a chancre it may 
safely be estimated that mfection occurred previously 
between ten and thirty days. 

The chancre or syphilitic initial lesion appears at the 
site of inoculation. Its recognition, when first exhibited 
as the earliest indication of a serious disease, is a matter 
of the profoundest importance, seeing that the welfare 
of the individual, and often of others with whom he sus- 
tains intimate relations, may be conditioned upon its cor- 
rect diagnosis. 

The chief error committed by the practitioner and 



32 SYPHILIS AND THE VENEREAL DISEASES. 

student anxious to master this problem lies in an effort 
to identify some particular chancre as a type of all 
others, and to base a diagnosis upon a comparison of 
others with this as a type. This is the familiar process 
by which men recognize in nature a flower or a bird, 
and in medicine a disease of so fixed a type as a corn or 
a carbuncle. 

The sole constant characteristics of every chancre are 
— {a) an incubative period preceding its appearance ; (b) 
a sclerosis, induration, or dense thickening of the base 
of the lesion, widely varying in grade and duration with 
different chancres ; {c) a simultaneous enlargement and 
induration of the gland or glands in nearest anatomical 
relation with the chancre, constituting the " syphilitic 
bubo," or primary adenopathy. The first of these con- 
stant characteristics is an historical symptom, a knowl- 
edge of which may be withheld from the practitioner at 
the date of his examination. The last, though wellnigh 
constant of occurrence, may not have been declared fully 
at the date of the examination, or the glandular enlarge- 
ment may be so slight or so deeply situated as to escape 
detection. It follows that in some cases it is possible 
that at a given moment the sclerosis may be the sole 
chancre-symptom present whereby the nature of the 
disorder may be declared. Yet there are several non- 
constant symptoms which can usually be recognized 
without difficulty, and which leave the observer in little 
doubt as to the diagnosis. These symptoms are for the 
most part explained later. 

A chancre is a modification of the sound or patho- 
logically altered skin or mucous membrane, occurring 
after syphilitic infection, and displayed after an incu- 
bative period, characterized by a circumscribed sclerosis 



ACQUIRED SYPHILIS. 33 

of tissue, and accompanied by an enlargement and indu- 
ration of neighboring glands. Every chancre means a 
syphilis, mild or severe, that will follow. Every case of 
acquired syphilis points to a precedent chancre, recog- 
nized or unrecognized. Every chancre, further, is a 
symptom not merely of a syphilis that will follow, but 
of a syphilis actually present. The proof is found in 
the fact that infection of a sound individual from such a 
chancre is followed by the development not merely of a 
new chancre, but also of a new syphilis. 

It is important to note at the outset, considering the 
definition given above, that a chancre may be either an 
isolated first lesion of syphilis or a mxodification of some 
symptom of another disease. Briefly, the study of 
chancres is the study less of lesions than of a series of 
singular modifications of lesions recognized in many 
other diseases, which, under the influence of syphilis, 
take on new aspects and undergo singular metamor- 
phoses. Thus, the chancre may develop upon the 
sound skin of the arm as a consequence of intentional 
experimental inoculation, or upon the sound mucous 
membrane of the vulva as the result of infection in the 
sexual act. It may also originate as an untoward modi- 
fication of a "cold sore" (herpes labialis) of the mucous 
membrane of the lip infected in the act of kissing, or be 
a significant change in the evolution of a vaccine vesicle, 
a blister on the finger, or an excoriated nipple. 

Chancres may thus be represented at one time or 
another by every recognized lesion of the cutaneous 
surface, including the macule, papule, vesicle, pustule, 
bleb, tubercle, tumor, and ulcer. Only the most com- 
mon types can here be enumerated conveniently. 

Erosion (Superficial erosion). — This is the least con- 



34 SYPHILIS AND THE VENEREAL DISEASES. 

spicuous, the oftenest ignored or misunderstood, and 
yet the commonest of chancre symptoms. It is rec- 
ognized as a roundish, oval, or quite irregular macule 
or spot resting, soon after its evolution, upon a delicate 
bed of induration, giving to the touch the sensation of 
a thin sheet of parchment or of mica let into the under- 
lying tissue. It is usually distinctly circumscribed, and 
exhibits a shallow or scarcely depressed erosion, cen- 
trally fixed or involving its entire face. In size it varies 
from a large pin-head to a bean, and may be many times 
larger. Its color is dull-reddish, grayish, or even whit- 
ish ; it often resembles in hue a section of raw ham. It 
may be dry and glazed, or slightly moist and secreting 
a thin serum which glues to its surface any dressings 
that may have been applied to it. At times it has a 
grayish-white film over its face, and may even have a 
diphtheroid aspect. It may be uniformly level with the 
neighboring skin, or its edges may be raised and its cen- 
tre slightly depressed. It very rarely suppurates freely 
or degenerates into a well-marked ulcer. These com- 
plications usually result from external irritation (caustics, 
mixed infection, urine flowing over the site, as in urethral 
chancre). The accidents of phagedena and sloughing 
are still rarer. When these chancres survive until gen- 
eral syphilis is declared, they are gradually transformed 
into symptoms of general syphilis, readily enlarging 
to elevated, granulating, rarely hemorrhagic masses 
smeared with a highly contagious puriform mucus and 
merging thus into the mucous patch and condyloma. 
These erosions may be lifted away from their original 
sites by extensive underlying scleroses, and be thus 
greatly modified in appearance. They are then changed 
from flat macules to large-nut-sized and even larger 



sv nil LIS. 



Plate 2. 




Chancre and papillary growths of the tongue (Hutchinson). 



ACQUIRED SYPHILIS. 35 

irregularly outlined masses, ridges, and deformations 
of the lip, the vulva, or the preputial rim — favorite sites 
for their development. These odd-looking swellings, 
unlike each other and conspicuous chiefly for their 
irregular bulging, often as firm as ivory to the touch, 
are capped at one point or another by the smooth, shal- 
low, dry and glazed or slightly secreting erosion 
described above. All are essentially giant-papules, 
undergoing a special evolution because of the pressure- 
and friction-effects of their particular environment. 

Papule (Dry scaling papule; Non-ulcerating, indurated 
papule). — This is the common result of inoculation of 
the skin as distinguished from that of the mucous sur- 
face. The chancre is here evolved as a pea- to a bean- 
sized papule or papulo-tubercle, indurated at the base, 
dry, scaling, and colored in various shades, according to 
its situation. It is occasionally seen upon the skin of 
the penis as the result of accidental infection of that 
part, and upon other cutaneous surfaces, as the thigh 
and the arm, as the result of accidental or experimental 
inoculation. 

Ulcer. — Ulceration of the chancre is probably in every 
case the result of local irritation. This irritation maybe 
accidental, as in the case where improper dressings or 
applications are made to the lesions, or intentional, as 
where savin cerate has been applied or horse-hairs have 
been passed through the base for the purpose of exciting 
suppuration with a view to supplying a virus for purposes 
of experimentation. Two types of ulceration may be 
recognized in chancres, the shallow and the deep. Both 
occur in beds of induration. Their causes have been 
discussed above ; maceration (by mucus, by leucor- 
rhceal and blennorrhagic discharges), friction, improper 



l6 SYPHILIS AND THE VENEREAL DISEASES. 

treatment by local applications, filth, and neglect may 
all be cited as of consequence. 

Shallow and Slip erficial ulcers^ scantily secreting serum, 
are usually imbedded like erosions in thin sheets of 
induration, but they may cap considerable elevations of 
tissue. Their edges are sloping, almost never clean-cut, 
punched out, or undermined ; their floors rarely slough ; 
their outline is irregular. At times they resemble shal- 
low fissures, especially on the side of the fraenum ; at 
others they form at the bottom of a crevice between two 
walls of induration, as when the sclerosis involves the 
mucous membrane of both the corona glandis and the 
adjacent prepuce. 

Deep ulceration of chancres invariably results from 
the action in excess of the causes suggested above, or 
from similar agencies. The " Hunterian chancre," so 
named because Mr. Hunter believed that it was the sole 
precursor of general syphilis, is a deep excavation in a 
large mass of induration. This crateriform ulcer is 
roundish, oval, or very irregularly shaped, often with a 
floor set in an angle, presenting thus the aspect of a 
deep fissure in a neoplasm. Its secretion is commonly 
scanty, though when profuse it may be hemorrhagic ; 
its edges are sloping; its rim is densely indurated, cap- 
ping a tumor-like mass varying in size from a hazelnut 
to that of a pullet's egg. 

Mixed Chancre. — By this term is generally desig- 
nated a venereal lesion which at the outset, usually a 
brief time after infection, exhibits all the characteristic 
features of the soft chancre (" chancroid," " chancrelle," 
etc.), but which, after a due incubative period has elapsed, 
becomes specifically indurated at the base, is accom- 
panied by syphilitic bubo, and later is followed by gen- 



ACQUIRED SYPHILIS. 3/ 

eral syphilis. This accidental implantation of the virus 
of syphilis upon a soft chancre (or upon its site before 
the appearance of the latter) is analogous to the com- 
plication which ensues when a herpetic vesicle ('' cold 
sore ") of the lip or a cigarette-burn of the same region 
becomes infected with the virus of syphilis. In these 
cases it is the modification of the original process that 
announces the syphilitic complication. 

The chancroid or " soft chancre " is essentially a 
pustular lesion, and its purulent secretion, whether from 
pustule or from suppurating abrasion or fissure, is indef- 
initely auto-inoculable, as distinguished from the secre- 
tion of the syphilitic initial lesion, which is scanty and 
non-auto-inoculable ; hence all infecting chancres secret- 
ing an auto-inoculable pus are of the "mixed" type. 
The bubo, also, accompanying the soft chancre is usually 
inflammatory and has a tendency to suppurate, as dis- 
tinguished from the dense multiple buboes of syphilis, 
which rarely suppurate and are often non-inflammatory 
in type. It follows, then, that the buboes of " mixed 
chancre " may exhibit the features of one or the other 
of the two disorders thus commingled. The important 
point to recognize is that syphilis may ensue after the 
occurrence of ''mixed" chancre; and this possibility 
should never be forgotten in making the prognosis of 
any suspicious venereal sore. The individuals most 
often exhibiting these " mixed " chancres are of the pau- 
per class frequenting public dispensaries and out-patient 
departments of hospitals — persons whose female asso- 
ciates are as uncleanly as they are vicious. 

Another " mixed " variety, in the light of modern sci- 
ence, is the chancre of syphilitic origin that is also later 
infected with micro-organisms. This complication is 



38 SYPHILIS AND THE VENEREAL DISEASES. 

more common than is generally supposed. All the pus 
cocci, several of the mucors, and a large number of for- 
eign substances, usually inert, may often be recognized 
in chancres, especially in those of the filthy, but also 
of those who never previously suffered from venereal 
disease, and who, in ignorance or as the result of im- 
proper advice, suffer from neglect of cleanliness or from 
positive aggravation of the original disease. 

Chancres of the Syphilized. — Persons infected with 
syphilis have usually but one attack in a lifetime. The 
exceptions to this rule are so rare as simply to enhance 
its value and importance. But the recent as well as the 
veteran victims of that disease expose themselves to it 
and to other venereal diseases with results which de- 
mand exact recognition. 

Such persons, of course, may contract " soft chancres." 
But when exposed to fresh sources of syphilitic virus 
they occasionally exhibit, as a result, chancres of a for- 
midable type and an obscure character, requiring some 
expertness for their proper recognition. Some of these 
results are (a) lesions like soft chancres, but atypical, 
less clean-cut at the edge, with much less purulent secre- 
tion, and non-auto-inoculable ; [b) slightly indurated 
chancres, strongly resembling the initial erosion chancre, 
without accompanying syphilitic bubo, and disappearing 
without leaving results of consequence ; (c) large indura- 
tions with deep central excavation, at times strongly 
resembling the " Hunterian " chancre, yet without bubo, 
and yielding completely to proper internal treatment. 
Some of all these are, without question, gummatous (so- 
called " tertiary ") lesions of general syphilis, occurring 
with reawakened activity where, at the site of invasion, 
new bacilli have been introduced. Yet rarer are {d) pea- 



ACQUIRED SYPHILIS. 39 

sized and larger, exceedingly dense, circumscribed thick- 
enings of the genital region, without erosion, ulcer, or 
hypersemia, and due to the causes named above. 

Location of Chancres. — As distinguished from chan- 
croids, which are very rarely extra-genital in site, 
syphilitic chancres may occur upon any exposed por- 
tion of the body-surface; very rarely indeed do they 
develop at long distances from the mucous orifices of 
the body (as, for example, in the bladder, oesophagus, 
stomach, etc.). The genital region of the two sexes is 
most often involved merely because of the frequency of 
transmission in the ample opportunities of the sexual 
act. In this way the balano-preputial sulcus, the rim 
and inner face of the prepuce, the fraenum, glans, and 
integument of the penis, the scrotum, the inner face of 
the thigh in contact with the latter, and the perineum 
become common sites. Urethral chancres are rarely 
deeply situated, but they may commonly be recognized 
at the tip of the glans in men, where the indurated mass 
encroaching upon the limits of distensibility of what 
may be termed the " urethral nozzle " produces so much 
local irritation and consequent sero-purulent discharge 
that the symptoms are often mistaken for those of a 
blennorrhagia. When the glans in these cases is 
grasped firmly between the thumb and the finger, the 
induration may be felt, resembling a short section of a 
clay pipe let into the submucous tissue, and at the 
moment of pressure a characteristic whitening of the 
rim of the labia of the meatus urinarius bears witness to 
the extreme thickening of the initial lesion. 

In women the labia majora and minora, the four- 
chette, the os uteri, the clitoris, the vestibule, the meatus 
urinarius, and, very rarely, the point of the superior 



40 SYPHILIS AND THE VENEREAL DISEASES. 

commissure of the vulva are the usual sites of chancres. 
In these situations their transformation in situ to condy- 
lomata, mucous patches, and other secreting lesions of 
systemic disease is readily effected in consequence of 
the heat, moisture, and friction to which they are here 
exposed. In women the deformities of the genital 
region, venereal in origin, are commonly of exaggerated 
type, and, as a rule, in fetor, in abundance of secretion, 
and in volume they far exceed the corresponding lesions 
of the other sex. 

Chancres of the vagina are rare ; when they occur 
they usually escape observation. They are probably 
more common than is set down in the statistics of the 
malady. Chancres of the mucous envelope of the 
cervix are usually visible on its anterior limb. They are 
reddish or empurpled excoriations with an engorged 
areola ; their face is often covered with a pultaceous and 
adherent film. In the genital chancres of women the 
inguinal glands usually escape involvement. 

Extra-genital chancres are not of rare occurrence in 
the larger cities, and, as already pointed out, may be 
recognized in every region of the body. The most 
frequent sites are the lips, fingers, nipples, anus, tonsils, 
tongue, nares, thighs, arms, and toes. They result from 
the contacts incidental to kissing, sucking, biting, 
vaccinating, the smoking of pipes, the nursing of chil- 
dren at the breast, the practices of sodomy, digital 
explorations and operations of the accoucheur, physician, 
and surgeon, and from many accidents of daily life. 
They belong, without exception, to the types of chancre 
already described, invariably following periods of incu- 
bation, occurring with well-marked induration, and 
accompanied by adenopathy of the glands in the vicinity 



ACQUIRED SYPHILIS. 4 1 

of the infected part. Some are densely indurated fis- 
sures (nipple, anus, lip) ; some are indurated dry papules 
(as after vaccination, biting, tattooing) ; some are flattish 
plaques of a dull-red hue, or ulcers covered with an 
ashen paste (tonsils, tongue, uterus); some are irregu- 
larly shaped tumor-like masses (lips) ; some, finally, are 
simply symmetrical ovoid thickenings of normal tissue 
(finger, toe, hang-nail, etc.). 

Number of Chancres. — The initial lesions of syphilis 
are seldom multiple ; most often they are single. If 
dual in number or more numerous, they are, as a rule, 
multiple from the beginning. In these cases the infer- 
ence is just that there has been a simultaneous acci- 
dental inoculation of all such points at a given moment. 
The non-auto-inoculability of the secretion of the initial 
lesion forbids its multiplication upon the person of an 
individual once infected, even as the result of an acci- 
dent. The auto-inoculability of the pus of the "soft 
chancre," on the contrary, offers abundant opportu- 
nities for its spread from one point to another of the 
subject of the disease, and at the same time furnishes 
ample supplies for infection at any given moment in 
several points simultaneously. It follows that while in 
exceptional cases a patient may exhibit at one time two 
or three initial lesions of syphilis on his person, he 
never compares in multiplicity of chancres with, for 
example, a woman whose labial sores have supplied a 
pus streaming over the perineum where fifty, and even a 
hundred or more, soft chancres may at times be 
counted. 

Induration of Chancres. — The specific induration of 
the initial lesion is one of its constant features. This 
sclerosis is recognized by the sense of touch in varying 



42 SYPHILIS AND THE VENEREAL DISEASES. 

degrees as a distinctly defined thin plate or sheet of 
inelastic tissue let in beneath the excoriation, ulcer, etc., 
or as a dense mass with the hardness of ivory or carti- 
lage, varying in size from a split pea to that of a pullet's 
^gg' and even to masses still larger. At times the 
sclerosis is so dense as to suggest the hardness of 
marble. All these grades of induration are in part 
correlated to the degree of irritation to which, after its 
complete evolution, the chancre is subjected. The 
situation of the chancre is a factor determining in part 
the extent of the induration, as chancres of the vagina 
are proverbially less indurated, and those of the muco- 
cutaneous borders (lips, preputial orifice, etc.) more 
conspicuously sclerotic, than others. The induration 
may precede or follow (much more often the latter) the 
evolution of the chancre, or it may first be observed at 
the moment of detection of the sore itself The very 
late occurrence of induration in a chancre is usually a 
portent of good, as a delay of from twenty to thirty 
days after the appearance of a lesion supposed to be a 
precursor of syphilis usually negatives the expectation 
of that disease. The sclerosis may disappear before the 
healing of the chancre, or, what is quite common, may 
persist long after the involution of the latter, and even 
long after the occurrence of general symptoms. Occa- 
sionally one may recognize the pigmented, pigmentless, 
or sclerotic, keloid-like relics of induration six months 
after infection, and even after all symptoms of general 
syphilis have for the time disappeared. Sooner or later 
the induration always wholly disappears, and for the 
most part leaves behind it no traces of its existence, 
these facts seeming to bear no relation to the future of 
the patient. The so-called " relapsing indurations " are 



ACQUIRED SYPHILIS. 43 

usually syphilomata, evidences of general syphilis, so- 
called "tertiary gummatous mfarctions of the genital 
region." 

The Portent of Chancres. — While it is true that 
every initial lesion of syphilis signifies that a syphilis, 
mild or grave, will ensue, it does not follow that from 
the number or the appearance of chancres a prognosis 
may be made as to the severity or the reverse of the 
ensuing disease. An exceedingly insignificant looking 
ham-colored spot in one individual may be followed by 
the most malignant form of the disease, and may lead to 
a syphilis of the second generation that may destroy in 
succession the fruits of a wife's pregnancies ; while a 
group of three gigantic masses of sclerosis, each with 
excavations of an ulcerative type, may be followed by 
even meagre results. The reason for this disproportion 
may be found, as some allege, in the activity of the 
germs present, but it is more probably due to the kind 
of soil in which those germs are implanted. 

Duration of Chancres. — Chancres may persist until 
the evolution of systemic syphilis. They may, however, 
be resolved and disappear almost wholly at an earlier 
date. When persisting still later, they are always 
changed to conform to the type of the general symp- 
toms of the disease, and are in reality no longer 
chancres, but condylomata, granulating mucous patches, 
gummata, etc. When persisting to such a late stage, 
they usually announce the fact by significant changes, 
such as elevation of the surface, tumefaction of the 
mass, softening of the sclerosis wholly or in part, and 
hypersecretion. 

Termination. — Chancres may terminate by complete 
resolution. However numerous and formidable in 



44 SYPHILIS AND THE VENEREAL DISEASES. 

appearance, they rarely result in any mutilation of the 
part in which they have been seated. The simplest 
lingering traces of their existence are either moderately 
pigmented patches, such as occur on the skin of the 
penis in young subjects with very dark hair and eyes, 
or, as a sequence of such pigmentations in that class 
of individuals, even non-pigmented plaques as large as 
the original chancre, being, in fact, pigmented spots 
whence the pigment has slowly been removed. Chan- 
cres seldom leave scars, for the reason already given, 
namely, their indisposition to undergo ulceration. In 
this respect they are strongly distinguished from soft 
chancres, which, as a rule, suppurate and ulcerate, and 
often leave punched-out scars as relics of their ravages. 
When syphilitic chancres actually leave scars, these are 
always the result of ulceration, and this ulceration is the 
fruit of some accidental complication of the local 
disease. Thus, the chancre of the urethra lies just 
where the stream of urine several times in the day 
necessarily passes over its entire face, and, this fluid 
being in a high degree irritating in consequence of the 
urinary salts it contains, the chancre often secretes quite 
freely, and may leave an odd-looking scar at the tip of 
the glans penis, this organ, after all is healed, looking as 
though it had lost its apex, while the external urinary 
meatus has for a distance of perhaps half an inch or 
more a " reamed-out " aspect. Deeply-cauterized and 
filthy chancres, as well as those of " mixed " type, may 
leave small cicatrices. It follows that in making exami- 
nations for the army and navy and for life insurance, the 
non-discovery of scars upon the progenital region of 
men does not prove that they have not had a preceding 
syphilis, and the actual discovery of such scars in the 



ACQUIRED SYPHILIS. 45 

progenital region is by no means conclusive that the 
subjects of the same have been syphilitic. 

Diagnosis. — The diagnosis of the initial lesion of 
syphilis is made chiefly by a careful study of the symp- 
toms already detailed. By the recognition of these 
special characters, rather than by the exclusion of the 
symptoms of other diseases, is the end best reached. 

The chancroid or " soft chancre " is usually a pustular 
lesion, and is represented either by an unbroken pustule 
surmounting its characteristic sharply-cut ulcer, or, after 
the rupture of the pustule, by the pus-bathed ulcer itself, 
circular, oval, stellate, or linear in outline. However 
engorged its base, the latter is never indurated save in 
the " mixed " variety. There is no period of incubation, 
and, though at times single, the lesions are usually 
multiple and often exceedingly numerous, scores form- 
ing in extreme cases. The adenopathy of chancroid is 
represented usually by a single though occasionally by 
a double bubo. Rarely many buboes occur of a dis- 
tinctly inflammatory type, with a tendency to suppura- 
tion and the production in the lips of the wound, when 
there is spontaneous bursting of the gland-abscess, of a 
chancroid by secondary infection. The purulent secre- 
tion of the chancroid is practically indefinitely auto- 
inoculable — a fact accounting for the multiplicity of the 
lesions in many cases. Chancroids are usually genital 
in situation ; rarely are they extra-genital, with the 
exception, particularly in filthy women, of the anus. 
The floor of the chancroidal ulcer is usually covered 
with a more or less tenacious slough resembling wet 
chamois-skin, and presenting in this particular a marked 
contrast with the shallow, scantily secreting, indurated, 
and sloping edges and floor of the initial lesion of 



46 SYPHILIS AND THE VENEREAL DISEASES. 

syphilis. Lastly, the accidents of sloughing, phagedena, 
and enormous involvement of the skin and the subcu- 
taneous tissues of the thigh in ulcerative and burrowing 
sinuses are almost unknown in syphilis of the cleanly, 
and are by no means of very rare occurrence in chan- 
croids of all classes of patients. 

The lesions of herpes progenitalis are very readily 
differentiated from syphilitic chancres. The former are 
transitory, lasting at the longest for but a few days — a 
feature of prime importance in establishing a diagnosis, 
for any so-called " herpetic lesions " followed by ulcers 
lasting for ten days are probably not such, and should 
be viewed with great suspicion. Herpetic lesions in the 
progenital region are essentially vesicular, and are visi- 
ble either as vesicles or as the relics of vesicles in the 
form of very superficial reddish plaques, where delicate 
and lightly-tinted crusts appear, or as slightly raw and 
tender, finger-nail-sized spots, furnishing a serum suffi- 
cient in quantity to moisten an applied bit of cotton. 
Their cause, further, may often be determined without 
great difficulty (venery, pollutions, gastro-intestinal de- 
rangements such as constipation, chills, gouty attacks, 
etc.). 

Balanitis. — In this affection, as in herpes progenitalis, 
the disease, as distinguished from all varieties of chancre, 
is always short-lived and yields readily to treatment. In 
typical lesions the mucous membrane of the sac of the 
prepuce and of the glans penis becomes reddened, tumid, 
and in extreme cases of a deep purplish hue, with super- 
ficial excoriations of the external layer of the membrane 
in plate-like, finger-nail-sized plaques, which can be 
studied best in a well-marked case of blennorrhagia of 
the conjunctival membrane. There are distinct sensa- 



ACQUIRED SYPHILIS. 47 

tions of itching- and burning in the part, and the odor 
of the secretions is usually nauseous in consequence of 
the altered character, in this part, of the secretion from 
the glands of Tyson. There is no induration, no gland- 
ular complication, and never ulceration. The disorder 
is usually relieved, when not complicated, in the course 
of a few days by the application of a stimulating vinous 
lotion aided by astringents, a thin layer of absorbent 
cotton being interposed between the two folds of mem- 
brane in contact. 

Verruca Acinnmata (" Venereal warts," Moist warts, 
Condylomata, etc.). — Filiform, papilliform, single or mul- 
tiple, often numerous, vegetations m.ay develop, for the 
most part in the progenital region of the two sexes. 
These warty growths are usually pedunculated, but at 
times are flattened. They secrete a mucoid fluid of 
offensive odor; this fluid in syphilitic subjects is highly 
contagious. The growths vary in size from a pin-head 
to compound masses as large as the fist and even larger. 
As distinguished from chancres, they are never indu- 
rated, they rarely ulcerate, they are not accompanied by 
adenopathy, and they survive for periods of time far out- 
lasting the life-history of even persistent initial lesions of 
syphilis. They may occur in virgins, but they are more 
common in the subjects of venereal disorders, as also in 
those suffering from leucorrhceal and other pathological 
fluids bathing the genital region. Rarely they have an 
extra-genital site, such as the face. In males they are 
apt to form in the sulcus behind the corona glandis, 
about the fraenum, in the external orifice of the urethra, 
and over the scrotum; in women, chiefly about the four- 
chette and the labia. They are readily recognized by 
their resemblance to the comb of a cock, by the absence 



48 SYPHILIS AND THE VENEREAL DISEASES. 

of ulceration and of induration of the base, and, when 
wiped clean, by their florid aspect and their readiness to 
bleed when scraped or cut away. 

EpitJielioDia of the genital organs occurs most com- 
monly after the middle periods of life in both sexes — 
ages when chancres are decidedly of less frequent occur- 
rence than at others. In men the most frequent site of 
the disease is the glans penis, where a circumscribed, 
flattened papule, verrucous elevation, or shallow erosion 
may occur. The period of duration of these lesions is 
for most cases far greater than that of either chancre or 
gumma. The base of one or two of these primary 
growths may become indurated and the neighboring 
glands may enlarge ; but the inactive, often slightly 
hemorrhagic or crusted papule or warty growth seated 
upon an infiltrated tissue, with an ulcer forming only 
after a long evolution of the primary symptom of the 
disease, is not to be mistaken for a chancrous lesion. 
When actually ulcerating, the resulting ulcer is of the 
type of the epitheliomata of the skin in general, with 
serous, scanty, or bloody secretion, everted edges, and 
excavated, often eroded, floor. For women the region 
of preference in the progenital forms is the clitoris, 
where the lesions above described may occur occasion- 
ally with striking deformity of the parts. The non- 
inflammatory, often scarcely colored thickenings, ero- 
sions, warty growths, etc. of both labia and clitoris, in 
women past the menopause, are all to be separated from 
chancrous changes. 

Molluscum epitheliale of the genital region in young 
persons, especially those of the male sex, is characterized 
by the occurrence, on the scrotum chiefly, of split-pea- 
sized, yellowish-white, waxy-looking, and imbedded or 



ACQUIRED SYPHILIS. 49 

projecting bodies, usually exhibiting at one point or 
another of their globular surface a whitish or blackish 
punctum representing the occluded orifice of a sebaceous 
gland. They may be few in number, but often they are 
exceedingly numerous, studding the region affected with 
isolated but closely approximated lesions. They are 
never ulcerated, indurated, inflammatory, nor the seat 
of evidence of any acute process. It is impossible for 
the trained physician to mistake them for chancres, but 
the error is occasionally made by young and timid lay 
patients, who, having for good reasons become anxious 
about exposure to disease of the affected part, discover for 
the first time, on careful scrutiny, the molluscous bodies, 
and are filled with terror at the sight. There is never any 
glandular complication of these simple lesions, and in any 
doubtful case the expression of the cheesy mass from 
the orifice of the gland would establish the diagnosis. 

Lichen planus of the genital region, particularly in the 
male sex, is at times liable to be mistaken for chancre. 
But the lesions are always papular, dry, and flattened at 
the apex, with a singularly characteristic polygonal out- 
line, often very sharply defined. They are never seated 
on an indurated base, are not accompanied by glandular 
enlargement, are not eroded nor ulcerated, and are 
usually multiple, with at times marked invasion of the 
skin of the lower belly and the adjacent region of the 
thighs. An interesting feature of lichen planus of the 
genital region is the grouping of the lesions in lines, so 
that at times half a dozen or more of the small crimson, 
reddish, purplish, or dull leaden-hued papules stretch in 
a direct line from one point to another over the dorsum 
of the glans penis, in the skin of the organ. Angular 
as well as rectilinear figures, and even odd-looking 

4 



50 SYPHILIS AND THE VENEREAL DISEASES. 

cockades, may thus be formed. Lichen planus lesions 
of the genital region are often the seat of intense itch- 
ing, and may be well scratched with the evidences of 
such traumatism upon and about them. They com- 
monly persist for a period of time much longer than 
that limiting the continuance of chancres. 

Psoriasis of the genital regiojt is exposed in well- 
defined disks covered, as a rule, with large-sized lami- 
nated scales, the disks varying in size from a pin's head 
to that of a silver dollar and even larger. They occur 
upon the skin of the penis and the scrotum, with fre- 
quent involvement of the pubic region, lingering near the 
line of the hair and projecting beyond the latter upward 
and downward. The absence of secretion, of induration, 
of ulceration, and of glandular complication, and the 
frequent presence of the disease in other regions of the 
body, suffice to determine its character. 

The late gummatous (** tertiary ") lesions of geiieral 
syphilis occurring in the genital region are exceedingly 
liable to be mistaken for chancres. Here the diagnosis 
rests upon the discovery, elsewhere upon the person, of 
the relics of a preceding syphilis, the frequently obtain- 
able history of such a disease, the well-marked tendency 
of the late deposits of syphilis to ulcerate and spread by 
serpiginous destruction of the tissue involved (a rare 
complication of infecting chancres), and often upon a 
history of persistence of the gummatous thickening or 
ulceration for a time longer than that required for the 
fullest evolution of both chancre and general consecu- 
tive syphilis. The chancres of the syphilized, previously 
described, are often illustrations of this singular process, 
suggesting the origin of the mucous patch in the mouth 
of the tobacco-chewer, and in doubtful cases only the 



ACQUIRED SYPHILIS. 5 I 

most careful study will suffice to distinguish between the 
two.^ 

Patholog-ical Anatomy of Chancres. — As the syphi- 
litic chancre is like and unlike all other cutaneous and 
mucous lesions, and as the eruptions of syphilis are like 
and unlike all cutaneous affections, so the minute 
anatomy of chancres resembles that of many other 
pathological formations. Under the microscope one 
finds granulation-cells within reticulated fibrous meshes, 
and cell-infiltration partially or wholly blocking up the 
lumen of the vessels. Where erosions have occurred, 
naturally the epidermis is in various degrees removed, 
and the papillae, with little or none of the rete left, are 
exposed or are even in great part removed. The 
characteristic induration of the chancre is due in part to 
new-formed connective tissue and in part to epidermal 
thickening. It is highly probable, however, that the 
lymph of the part is profoundly affected by a special 
ferment produced by the bacilli responsible for the 
disease, when the latter first multiply in exterior regions 
of the body. The absence of dense induration of 
chancres of the vagina and the cervix points conclu- 
sively to the fact that induration is a condition of site 
rather than of infarcted vessel or of multiplying connec- 
tive-tissue fibres ; and the extreme indurations seen at 
the muco-cutaneous margins of the body point equally 
to the action in those regions of a special influence upon 
the effective germs of the disease. 

Treatment of Chancre. — Persistent efforts have been 
made from time to time to set aside the possibility of 

^ For a tabulated summary of the diagnostic differences between chan- 
cre and other genital lesions, consult the section devoted to the subject 
of Chancroid. 



52 SYPHILIS AND THE VENEREAL DISEASES. 

sj^philis following chancre by the radical destruction of 
the latter. The reasonableness of success in these 
efforts is on a priori grounds so great that in all proba- 
bility they will never be abandoned wholly, but the 
actual results have thus far been disappointing and, for 
reasons that need not here be set forth, are enveloped 
in considerable doubt. The destruction of chancres by 
chemical agents and by the actual cautery has repeat- 
edly failed not only to relieve the local symptoms, but 
also to prevent the occurrence of general symptoms. 
The same may be said of total excision of the primary 
lesion, and even of total excision of both primary sore 
and all the glands in the neighborhood involved in the 
disease. When the chancre, as is usual after cauteriza- 
tion, exhibits increased induration of its base, even 
though it may not be affirmed that the ensuing disease 
is the graver for the complication, it is certainly true 
that the chancre is less manageable than before. In 
some cases exceedingly grave destructive ulceration 
following gummatous deposits has occurred in patients 
where these attempts have been made with all possible 
precautions to jugulate the disease in sound men. In 
this connection it must not be forgotten that even 
experts may be deceived in the recognition of both the 
chancres of syphilis and the lesions closely resembling 
the latter; and this possibility of error should not be 
ignored by the practitioner who is reasonably judicious. 
There is still a division among authorities on the ques- 
tion whether the initial sore is merely a local point from 
which, after sufficient multiplication, the microbe of the 
disease or its toxine is swept through the general 
economy, or whether the chancre is the local expression 
of an intoxication generalized at the outset. 



ACQUIRED SYPHILIS. 53 

All chancres should be treated by strict observance 
of the requirements of hygiene. The affected part 
should be cleansed with warm water and soap, after 
which washings in hot borated solutions should be 
employed. In the event of tenderness or pain, as in 
the case of chancres of the pendulous portion of the 
penis, the part, when practicable, may be immersed in 
hot solutions of boric acid often each day, or even in 
extreme cases for hours at a time. After drying, the 
chancre should be well dusted with powder, such as 
boric acid (or boric acid and talc, i part to 4, when the 
acid itself is at all irritating), europhen, aristol, hydro- 
naphthol(i part to 100 of fuller's earth), calomel (or i 
part of the latter to 3 or 4 parts of starch), or iodoform 
when the odor of the drug can be tolerated, and especially 
in the case of painful, intractable, or irritable chancres. 
When erosions form, having a raw, reddish, slightly 
secreting surface, and also when ulceration occurs, it is 
generally well to paint the surface of the sore, after the 
washing and before the application of the powder, with 
a solution containing from i to 2 grains of the bichloride 
of mercury in the tincture of benzoin. The drying, over 
the eroded surface, of the gum thus medicated is usually 
not unpleasant to the subject of the disease, and is also 
cleanly, protective, and efficient as a parasiticide. After 
all applications have been made, the surface, when prac- 
ticable, should be guarded from contact with neighbor- 
ing parts, not with a view to the prevention of auto- 
infection (which in these cases is not to be feared), but 
in order to set aside the possibility, always great, of 
irritation of the sore. In the instance of chancres which 
may be by this means sufficiently well dressed (sac of 
the prepuce, fraenum, etc.), when practicable, it is well to 



54 SYPHILIS AND THE VENEREAL DISEASES. 

draw the foreskin well over the interposed lint. As a 
rule, when the chancres are large and tender the male 
organ should be wrapped in a thick jacket of mercurial- 
ized wool and be brought up in the line of Poupart's liga- 
ment before the clothing is readjusted. Elastic or other 
ligatures should never be fastened about the penis. 

In women the labia, when similarly affected, should 
be separated by antiseptic cotton, and for chancres of 
the cervix pledgets of lint, after dressing the part, 
should be pushed against the os with tampon supports. 
For these chancres the mercurialized benzoin lotion is 
an excellent application. Lotions often useful when 
chancres prove Irritable under other treatment are the 
ordinary black wash, pure or diluted, and applied by 
the aid of moistened pledgets of lint ; tannic acid and 
red wine, i part of the former to 30 of the latter ; in 
some cases the lead-and-opium wash. As a rule, all 
salves and unguents are to be discarded in the manage- 
ment of chancres. The chief exception to the rule is 
furnished by lesions which secrete a fluid gluing the 
dressing so tightly to the part that when the lint which 
has been applied is removed no little pain is experienced 
and slight hemorrhage ensues. In this event, after the 
applications described above, the sore should be dusted, 
and then there should be applied lint on one face of 
which (that next the chancre) has been smeared car- 
bolized vaseline. 

In the management of chancres of the urethral orifice 
a bit of medicated lint may be introduced into the gaping 
orifice if required ; but the most important of the meas- 
ures to be followed is the immersion of the penis, when- 
ever practicable, in a basin of warm water at the time of 
each urination, as by this means the urine is in a measure 



ACQUIRED SYPHILIS. 55 

diluted at the time of its traversing the sore. Weak solu- 
tions of the nitrate of silver, employed not as a caustic 
agent, but with a view of making a satisfactory dressing 
of an eroded surface, may also at times be used with 
advantage. 

The question whether the treatment of syphilis should 
be begun at the date of recognition of the chancre or at 
the time of the appearance of symptoms of general 
syphilis is considered elsewhere. Internal medication, 
however, of a patient affected with a chancre which has 
been recognized as indubitably an initial lesion of syphi- 
lis is by no means necessarily the treatment of that 
syphilis. Infecting chancres are peculiarly responsive to 
a properly-directed treatment by internal medicine, and 
the refusal to employ the latter is unwarranted when the 
diagnosis is practically assured and the lesions are either 
painful, portentous, or the source, as is often the case, 
of much mental distress to the patient. Mercury by 
the mouth is in these cases the one efficient remedy. 
It should not be ordered unless the diagnosis is satis- 
factorily established. In the majority of all cases com- 
ing under the management of experts the diagnosis is 
practically ensured from the first, either as the result 
of confrontation (discovery, in the person from whom 
infection was received, of lesions capable of conveying 
the disease) or of the recognition of classical features 
of an initial sclerosis in the person acquiring the 
sore. 

It should not be forgotten, then, that the mercurial 
treatment of this period is a treatment directed to the 
chancre, and not to the as yet undeveloped disease to 
which the chancre points. If this be borne in mind, 
the end is readily reached. The metal should be used 



56 SYPHILIS AND THE VENEREAL DISEASES. 

or disused, puslied to a higher dose or reduced in the 
quantity administered, according as resolution of the 
sclerosis is announced, the erosion begins to heal, and 
the affected part to assume its normal character as to 
size, color, and freedom from obvious lesions. 

The preparations employed are those useful in the 
general management of syphilis, to which reference may 
be made. The protoiodide of mercury in doses of from 
^ to ^ grain, calomel in doses of from ^-^ to \ grain, 
gray powder, the bichloride (less preferable for this 
special purpose, as, in the doses ordinarily well tolerated, 
its operation is slower), and the biniodide may each be 
employed. In all cases of anaemic patients the hygienic 
and tonic remedies useful in the management of general 
syphilis should regularly be employed. 

" Mixed " chancres do not call for destruction by 
cauterization. They are often tender and painful, and in 
these cases much trouble may be avoided by early and 
persistent use of the hot borated immersions and wash- 
ings described above. 

The buboes accompanying syphilitic chancre often 
require no treatment beyond that advised for the initial 
sore, whether local or by internal medication, as the 
progress of the one toward a favorable issue, or the 
reverse, is usually proportioned to the improvement or 
aggravation of the other. Often the glands are neither 
large, painful, nor tender, the patient scarcely appre- 
ciating the fact of their undue size and hardness. In 
other cases they are voluminous and are the source 
either of local distress or of discomfort experienced in 
the movement of neighboring parts (leg, thigh, arm, jaw, 
etc.). In this condition frequent ablution of the glands 
with water as hot as can be tolerated is the best, simplest, 



ACQUIRED SYPHILIS. 57 

and most grateful method of treatment, followed, when 
needed, by a weak mercurial salve well rubbed into 
the skin covering the glands — ammoniated mercury, lo 
grains to the ounce of lanolin and vaseline ; mercurial 
ointment, i part to lO of simple unguent. To either 
salve, when there is much pain and tenderness, a small 
quantity of the extract of belladonna or of the watery 
extract of opium may be added. These unguents should, 
however, be not too amply supplied with drugs of the 
narcotico-stimulant class, as, even in the strength of lO 
grains to the ounce, systemic effects have been induced 
after application to the groin. 

In the event of " mixed " bubo there commonly results 
abscess of the glandular contents and either spontaneous 
or artificial opening of the same. The treatment of this 
complication is that of the bubo of soft chancre. 

With the healing of the chancre, when this is secured 
before the onset of general symptoms, ends a tolerably 
well-defined phase of syphilis, the period once called 
that of " primary syphilis," the period of lesions for 
the most part localized. Yet here, even at the outset of 
the evolution of the disease, it is made clear that no 
sharply-defined limits or periods are observed. For, 
as has already been shown, the chancre may at times 
persist long after general symptoms have been declared, 
and traces of it may be discernible even when grave 
complications of general intoxication have occurred. 

The Evolution of Syphilis in Stages or Excur- 
sions. 

In the early part of the present century Fernel and 
Hunter were followed by the late eminent Philip Ricord 
in establishing for the evolution of syphilis an artificial 



58 SYPHILIS AND THE VENEREAL DISEASES. 

system based upon chronological data. This system 
commended itself to the medical men of the scientific 
world, and as a result it secured at an early date almost 
universal acceptance. According to this scheme, there 
were three " stages " of the disease : a " primary " stage, 
inclusive of the period of the infecting chancre and its 
accompanying adenopathy ; a " secondary " stage, last- 
ing from a few months to two or three years, in which 
appeared most of the syphilodermata and the disorders 
of the appendages of the skin and the mucous mem- 
branes ; and a " tertiary" stage, lasting indefinitely from 
the close of the secondary period until a final result was 
reached either in one direction or the other, with the 
absolute cessation of the malady. In this latter stage 
occurred most of the affections of the deeper tissues, of 
the viscera, the bones, the testes, the nervous centres, 
and the fibrous and subcutaneous structures. The 
" secondary " was supposed to follow the " primary," 
and the " tertiary " was supposed to follow the " sec- 
ondary " stage. 

The objections to this chronological scheme have 
been multiplying for the last few years, until it has 
become needful either to abandon wholly its ingenious 
suggestiveness or to admit it and its conclusions only 
with exception and reserve. First among these objec- 
tions may be named the implication that a classical 
syphilis should in its evolution persist throughout these 
three " stages ;" the fact being that, as statistics clearly 
indicate, the largest number by far of all cases of 
syphilis never exhibit any signs of a " tertiary " stage. 
Second, the implication was made that in any given 
stage, especially in the so-called " secondary," the 
evolution of symptoms observed a definite order like 



ACQUIRED SYPHILIS. 59 

that of the " stages," one crop, for example, of syphilo- 
dermata following another in a definite procession of 
symptoms ; the facts being quite opposed to such a 
course, seeing that a syphilis thus regularly evolved, 
however conformed to the artificial time schedule of 
the schools, is clinically never seen. Third, there was 
overlooked or ignored a series of facts in which the 
chronological order of the scheme was violently reversed, 
so-called " tertiary " symptoms following " primary " 
without the evolution of any lesions which properly 
belonged to a " secondary " stage ; while even the 
symptoms of the "secondary" period were at times 
found to succeed instead of preceding those described 
as " tertiary." Lastly, a fact of serious importance in 
the study of syphilis was to be considered — the fact that 
many, if not actually the larger number, of all cases of 
grave disease are thus grave from an early moment in 
the career of the malady, so-called "tertiary" symptoms 
developing with a degree of rapidity as startling as it is 
portentous. It was in recognition of these obvious and 
numerous violations of their chronological system that 
the French have been obliged to coin such explanatory 
phrases as "precocious," ''late," "tardy," "galloping," 
etc. — terms confessing the inadequacy of the time 
schedule, and yet employed not in the ordinary course, 
but in the grave crises of the malady — epochs when a 
fairly good working system should be ready and fitted 
for every emergency that may arise. 

In order to grasp intelligently the facts of syphilis as 
they actually occur, it is well to make no attempt to 
force them into accordance with an artificial scheme, 
however cleverly arranged and readily understood, but 
rather to classify them in natural divisions. Thus 



6o SYPHILIS AND THE VENEREAL DISEASES. 

studied, it will be seen that for the vast number of all 
cases of the disease there is no fixed line of demarcation 
between its consecutive phenomena, and no fixed period 
of time in which any given series of symptoms will be 
begun or concluded. From the. moment of infection to 
any conclusion which the disease may acknowledge 
there is a regular progression, not along one line, but 
along many lines, and these lines never alike or parallel, 
but divergent in a thousand directions. By classifying 
in certain groups these excursions along various routes 
a systematic knowledge of the evolution of syphilis 
may be obtained. Instead of a chronological schedule, 
one may more profitably, to use a different figure, 
employ the radii of a circle to represent to the mind the 
divergences of the different symptoms of syphilis from 
the fixed pathological centre represented by the initial 
lesion. 

The most of syphilitic histories may be traced along 
the lines of advance represented by the four divisions 
hereinafter described. From the point of infection each 
of these lines of advance, or excursions, represents, it 
should be remembered, not a narrowly-bordered path- 
way of symptoms, but a general direction, with varia- 
tions deflected on either hand to divergences from 
other directions — no single history, perhaps, following 
exactly the same course, but each trending near one or 
another of the excursions defined. 

I. Benig-nant Syphilis with Mild and Transitory 
Symptoms. — Upon one extreme in this category are the 
cases in which typical initial scleroses with characteristic 
accompanying adenopathy are followed by symptoms 
which are either not at all appreciated by the subject of 
the disease or which barely suffice to awaken his or 



ACQUIRED SYPHILIS. 6 1 

her attention. A slight efflorescence upon the abdominal 
surface, a few days of malaise, and the disease is at an 
end, irrespective of any treatment whatever. It is true 
that it has been claimed that grave syphilis eventually 
follows, but a sufficient number of these patients has 
been observed to substantiate the fact of a further 
complete immunity from all signs of the disease. 
Similar facts have been recognized in attempts at the 
production of the infectious granulomata in the lower 
animals, and even in the vaccination of heifers for the 
purpose of cultivating vaccine virus. There are simply 
some individuals who seem to be protected against the 
incursions of the disease by reason of an individual 
idiosyncrasy. 

II. Benig-nant Syphilis with Relapsing or Per- 
sistent Superficial Symptoms. — This is the excursion 
observed, in all probability, in the larger number of all 
cases of syphilis occurring in the white races, and 
especially among those inhabiting the northern por- 
tions of the American and European Continents. In 
this category are to be recognized the patients in whom 
typical chancres are followed by characteristic so-called 
" early " manifestations of general syphilis. But all the 
lesions which result are superficial, and whether, as is 
often the case, they prove relapsing or persistent for 
long periods of time, involution is finally reached with- 
out the production of any permanent relics of the pro- 
cess. These histories are usually those of skin-symp- 
toms (papules, scales, etc.) disappearing and reappearing 
— disappearing on the intervention of proper treatment, 
reappearing after neglect or discontinuance of the latter, 
or when the health, for any intercurrent reason, has 
been impaired, but never throughout producing a pro- 



62 SYPHILIS AND THE VENEREAL DISEASES. 

found depression of the system nor inducing cachexia. 
The disease from first to last has been a serious annoy- 
ance rather than a formidable enemy, and if the cause 
were not known and the results had not been dreaded, 
but little anxiety would have been awakened by its 
encroachment. 

It is these cases that furnish abundant proofs of the 
skill of the trained ph\'sician, and also of the tremen- 
dous energy exerted upon the health by its worst 
enemies, lack of proper hygiene, alcoholism, senility, 
debauchery, poverty, and prior wasting disease. 

The cases included in this category may without 
warning, and often inexplicably, exhibit the symptoms 
enumerated in any of the other excursions described ; 
but it is true that the majority of all cases under observa- 
tion develop along the line here suggested — that of 
symptoms relapsing or persistent and superficial, and, 
however persistent, never ultimately followed by destruc- 
tive results. In other words, patients of this large class, 
as a rule, entirely fail of exhibiting symptoms of the 
type described as " tertiary." 

III. Malignant Syphilis with Relapsing- or Persist- 
ent Profound Symptoms. — In this category are included 
the cases eminently of transitory type. They are speedily 
transferred by the best of management into the list of 
benign cases, or with and even without treatment are 
readily exchanged into the graver list of malignant 
cases catalogued in the fourth of the divisions here con- 
sidered. 

The malignancy of these cases is declared in the 
deterioration of the tone of the system, in the produc- 
tion of cachexia, and in some cases by the degeneration 
of lesions which in other patients are resolved without 



ACQUIRED SYPHILIS. 63 

producing permanent relics of the process. Here at 
times develop in the viscera, nerves, bones, etc. gum- 
mata which resolve under appropriate therapy ; at other 
times, when degeneration occurs, the repair is either 
satisfactorily good, or the damage resulting is so slight 
as not to interfere with the bodily health. The element 
of gravity is lacking in each case, however portentous 
at any one time may be the extent or the depth of the 
invasion. Often it is the fewness and depth, rather than 
the number and degeneration, of the lesions that justify 
the designation " malignant." It is in this class of 
patients, as in that just discussed, where the brilliant 
results of medicinal and hygienic treatment of the disease 
are most effectively exhibited. 

IV. Malignant Syphilis with Relapsing or Pro- 
found Lesions that are Ultimately Destructive. — 
In this division, represented probably by from 5 to 20 
per cent, at the most, of all cases of syphilis, are cata- 
logued the number of patients exhibiting signs of what 
may justly be described as grave syphilis. Here the 
disintegrating and ulcerating gumma destroys renal, 
nervous, hepatic, and osteoid cells, pierces through bone 
and cartilage with appalling rapidity, converts into one 
hideous chasm both the nasal and the oral cavities, 
produces the paralytic, the imbecile, the repulsively 
deformed, and at times pushes its destructive forces to 
a fatal result. For the most part, however, in acquired 
as distinguished from hereditary syphilis, even in grave 
cases a fatal result is not so much to be anticipated as 
is serious damage of the sort suggested. Syphilis in its 
worst manifestations and activities often mutilates, para- 
lyzes, and cripples, but it rarely kills. 

In this connection it is worthy of note that the fright- 



\ 



64 SYPHILIS AND THE VENEREAL DISEASES. 

ful coQsequences which hedge about the track of the 
disease are not more conspicuous than the rapidity with 
which it traverses its path. Often before the last traces 
of the infecting sore have disappeared the hard palate is 
perforated, the body is covered with sloughing ulcers, or 
the liver is stuffed with ominous nodules. Here there 
has been no chronological order, no possible interval for 
the occurrence of a " secondary " stage, no pause in 
which even the best of treatment might have averted the 
conclusion. It is these cases that have necessitated on 
the part of the French — who still, for the most part, 
adhere to the chronological order of syphilitic manifesta- 
tions — the adoption of such phrases as " galloping," 
'^precocious," and "lightning." Indeed, of all cases of 
syphilis really entitled to be termed '' malignant," it 
may be affirmed that the majority bear the impress 
of such malignancy in the rapidity of progress of the 
malady. 

It is in this division also that the great triumphs of 
science may be achieved. Even in the worst phases of 
syphilis — those chiefly displayed in the fourth of the 
classes here enumerated — repair may be made to ensue 
when the destruction has been gravest and the systemic 
results are most profound. 

Between these four radii most of the excursions of 
syphilis may be discerned. These lines are not all 
rectilinear; many lie along or near the main divisions, 
but pursue a tortuous course from chancre to complete 
relief of all symptoms, the line now curving toward 
malignancy, now recurving to the other side. As a 
rule, the graver the case the straighter the excursion ; 
the milder the symptoms the more numerous the 



ACQUIRED SYPHILIS. 65 

deflections toward one side or the other, with no wide 
divergence to either. Rarely the course of syphiHs is 
to be represented by a Hne wholly diverted from the 
first to the fourth of the main divisions of the circle 
here suggested. 

The determining influences which result in these 
divergences are of the highest importance. First 
among all may be named the character of the soil in 
which the germ is implanted. The very young, the 
very old, those weakened by other maladies, by lack of 
food and of proper hygienic environment, the victims of 
drink, of debauchery, of poverty, of inherited weakness, 
— all suffer early and often from the added burden of 
syphilis. Second is to be named the early and effective 
intervention of proper treatment. Cases which have 
been neglected, those in which the disease has long been 
either ignored or treated inefficiently, are apt, before 
others, to display formidable symptoms. A third cause 
is described by authors as the complication resulting 
from the implantation of the germ of syphilis upon the 
system contaminated with tuberculosis, struma, and 
such cognate disorders as rickets, but these coinci- 
dences are much rarer than is generally supposed. 

Fortunately for the future of the human race, the sub- 
jects of acquired syphilis are, as a rule, between the 
middle of the second and the conclusion of the third 
decade of life — a period when the system is best fitted 
to endure the severe ordeal to which, in this affection, it 
is reasonably sure to be subjected. With the ample 
opportunities for good treatment afforded in the English- 
speaking countries of the world, the majority of all vic- 
tims of disease eventually escape payment of its severest 
penalties, marry, and beget healthy children. Though 

6 



66 SYPHILIS AND THE VENEREAL DISEASES. 

afterward they may in some degree be reminded of their 
old enemy, even as the victim of an ancient pneumonia 
or a broken thigh has reason at times to recall his for- 
mer mishap, they go to their graves as do other men and 
women, with diseases of a different type, and with con- 
sequences unchanged by the infection wrought at an 
early period of life. 

The Evolution of Syphilis Subsequent to the 
Chancre. 

It has been shown that chancres may persist to a 
point of time long after the exhibition of signs of gen- 
eral infection. Often, however, the period which may 
be described as the chancre-stage has been completed 
fully before such general symptoms appear. The term 
" primary syphilis," as has been shown, was once em- 
ployed to designate this chancre-stage, and the next 
period of evolution of the disease was, as distinguished 
from that which preceded and that which followed, 
called the stage of " secondary syphilis." Between the 
two periods it was believed and taught that a distinct 
interval of pause or arrest occurred ; this interval was 
given the title of " the second incubation," as subse- 
quent in time to what was called " the first incubation " 
of the chancre. It is true that in many cases an appar- 
ent delay occurs after a distinct conclusion of the chancre- 
stage before general symptoms of syphilis are declared, 
but it is equally certain that in other cases there is no 
appreciable delay, and that in yet others, where such 
delay or pause seems to occur, it is due to an apparent 
rather than a real incubation. Its features, when studied 
with the utmost care and skill, are declared both in the 
§kin and elsewhere as symptoms of the gradual evolu- 



ACQUIRED SYPHILIS. dj 

tion of the infective disorder, without any well-marked 
arrest. The wide range ascribed to this period of sup- 
posed incubation — from a few days to as many months 
— is a sufficient indication of the lack of precision 
involved in the use of the term. In general, it may be 
said that from the date of the appearance of a chancre to 
that of appreciable general syphilitic symptoms from 
forty to fifty days may elapse. This supposed period of 
incubation is without question shortened in malignant 
and rapidly-evolved cases, and is lengthened in those 
where an excellent constitution of the patient, excep- 
tionally good treatment, or the mildness of the dis- 
order has interposed a barrier to the extension of the 
malady. 

It is wellnigh demonstrable, with the ample means at 
the disposal of the expert, that from the moment of the 
appearance of the chancre to the date of the onset of the 
earliest symptoms of generalized disease the signs of a 
gradual intoxication are with each day of its advance 
progressively apparent. These symptoms, often at first 
obscure, become usually much more obvious as the term 
of the supposed incubation draws to its further limit. 
Even, however, to the gross observation of the eye 
the victim of infection loses at the outset the usual 
appearance of health, and exhibits another which 
gradually acquires characteristic features — features by 
which, at times, the stadium of the disease may be 
recognized. 

The skin, especially of the face, which is most often 
exposed to the eye of the observer, assumes a peculiar 
sallow or muddy hue varying from a yellowish shade 
to a deep reddish, somewhat empurpled tint. The facial 
expression may be one of dejection ; there is often 



\ 



68 SYPHILIS AND THE VENEREAL DISEASES. 

cephalalgia, anorexia, vague or very well marked rheu- 
matoid pains, headache and backache, lassitude, neur- 
algia of various nerve-trunks, and, in cases, typical 
jaundice. By due exploration it may be discovered that 
transitory effusions have occurred beneath the perios- 
teum of exposed bones : there may be retinal hypersemia, 
hepatic and splenic enlargement, or albuminuria. The 
percentage of the oxyhaemoglobin decreases with the 
number of the red blood-corpuscles, while the leucocytes 
increase. It is during this period also that there occur 
thermal changes which have been summed up rather 
loosely under the term *' syphilitic fever." 

The febrile symptoms recognized in an early or a late 
phase of syphilis occur neither with sufficient frequency 
nor with sufficiently characteristic features to justify the 
employment of a distinctive term. These thermal varia- 
tions are most often of early occurrence, either before or 
soon after the exhibition of constitutional symptoms, and 
are in general due to the reaction of the system against 
the recently-introduced and multiplying toxine of the 
malady. Abnormal thermal variation may be wanting in 
more than 50 per cent, of all cases examined, or may be 
so slight as scarcely to attract attention ; or it may be in 
a high degree pronounced, the physician, unaware of the 
precise cause of the disturbance, not infrequently assum- 
ing that the patient is suffering from a tertian or quotidian 
miasmatic fever. In well-marked and classical cases the 
temperature prior to the earliest eruptive phenomena 
rises to 103° and even to 106° F., and may then assume a 
continued or intermittent type with vespertine exacerba- 
tion. The fever is rather more often observed in the 
cachectic and weak than in the strong, and is often a 
precursor, when well marked, of a severe type of con- 



ACQUIRED SYPHILIS. 69 

secutive symptoms. It is said to be more common in 
women than in men, but on this point there should be 
great reserve. Fevers occurring in other stages of the 
disease are usually symptomatic oi destructive processes 
due to the disease ; though it is to be noted that the 
subject of syphilis is often in a depressed condition, and 
furnishes a large field for the invasion of intercurrent 
disorders, such as la grippe and tonsillar and bronchial 
affections, several of which may excite febrile reactions 
not directly connected with the specific affection. 

Involvement of the Lymphatic Glands. 

The syphilitic bubo, or specific induration and enlarge- 
ment of certain glands in anatomical proximity to the 
site of infection, has already been described. It is at a 
period later in the evolution of the disease, and usually 
at or near the close of the so-called period of *' second 
incubation," that the lymphatic system (the glands, more 
particularly, of the several accessible regions of the body) 
exhibits characteristic changes. In well-marked cases 
one, if not quite all, of the glands which may be appre- 
ciated by the touch of the observer becomes enlarged, 
engorged, soft, and voluminous, as distinguished from 
the densely-indurated buboes accompanying the chancre. 
This ganglionic engorgement is one of the most constant 
of the signs of systemic syphilis, and though at times 
it may escape observation or actually be absent, it is 
so conspicuous a feature of some cases that patients 
themselves often call attention to it. At a given mo- 
ment it may be the sole appreciable symptom. It 
betokens, when well marked, a general intoxication, 
and, though not always proportioned to the intensity 
of the disease in any given case, it occurs at times as 



70 SYPHILIS AND THE VENEREAL DISEASES. 

the result of an individual predisposition to lymphatic 
disorders. 

The glands most often exhibiting these changes are 
the post-occipital, the chain extending along the pos- 
terior border of the sterno-cleido-mastoid muscles, the 
supraclavicular, the inguinal and axillary, the epitroch- 
lear, the submaxillary, the submental, and the femoral. 
At times the lymphatic trunks leading to these glands 
exhibit similar changes. 

The tumefied glands vary in size from that of a bean 
to that of a pullet's Q<g<g ; they are usually rounded or 
oval in contour, smooth to the touch, and painless; at 
times, however, they are very tender, and, when not 
overlying bony tissue, movable. They have no ten- 
dency to degenerate, in this respect exhibiting a very 
noticeable difference from the syphiloma, or gummatous 
involvement, usually of a single gland, occurring early 
or late in cachectic subjects. The syphiloma has a 
uniform tendency to become at one point or another 
reddened and porky to the touch, and it soon breaks 
down into a characteristic abscess. 

The voluminous and softish ganglia of early syphilis 
are found on examination to be constituted by a small- 
celled infiltration of the lymph-channels and a succulent 
fulness of the tissue about the latter. Resolution is by 
the ordinary absorptive processes. 

Syphilitic Cachexia. 

The anaemia and leucocythsemia of syphilis occur either 
as a direct and sole result of systemic intoxication or as 
the indirect result of the latter in individuals predisposed 
to cachexia in consequence of an enfeebled condition of 
the system or of constitutional inheritance. This condi- 



ACQUIRED SYPHILIS. ^1 

tion is well seen in the infantile forms of the disease and 
in the victims of debauchery, drink, poverty, hospitalism, 
filth environment, and of other affections than syphilis. 
Tuberculosis, rickets, and scrofulosis are less frequently 
responsible for this condition than is generally believed. 
The symptoms of syphilitic cachexia may be declared 
early or late — in the former event usually toward the 
close of the pre-exanthematous stage of the disease ; in 
the latter case at any time when the system exhibits 
signs of exhaustion in consequence of gummatous 
changes in bone, periosteum, nerve, or other important 
tissue of the body. 

The signs of cachexia are a peculiar dull-tinted pallor 
of the skin, with vague pains, persistent weakness, flab- 
biness of the tissues, a distinct whiteness of the con- 
junctivae, emaciation, and manifest disturbances of 
digestion, assimilation, and excretion. This condition, 
which may be produced solely by the disease and 
which may be relieved greatly by a properly-directed 
ferruginous and mercurial medication, may without 
question be induced or aggravated by the injudicious 
employment of mercury in the treatment of the disease. 

Syphilis in Relation with Coincident Injuries and 
Accidents. 

It was at one time believed, largely on rt:/r/<?n grounds 
and after insufficient observation of cases, that syphilitic 
infection, if relatively recent, predisposed its subject 
to the exhibition of special lesions or special disturb- 
ances when exposed to traumatisms or to diseases of a 
different origin. These views have been changed radi- 
cally since the date of a wider knowledge on the subject 
of the antagonism of toxines. 



72 SYPHILIS AND THE VENEREAL DLSEASES. 

As a matter of fact, the subject of recent syphilis 
exhibits a tendency to the production' of lesions at sites 
of irritation (condylomata about the uncleansed anus ; 
mucous patches of the mouth irritated by tobacco, 
smoked or chewed ; palmar lesions of the hand-worker) ; 
but it is also tolerably clear that for the most part 
syphilitic subjects undergo surgical operations (cachexia 
and its complications aside) with very much the same 
results as in the non-infected. They also exhibit the 
classical signs of local irritation, not different from those 
seen in others (urticaria from the attacks of vermin ; 
erythematous redness on the application of a sinapism ; 
zoster after exposure of a nerve-trunk to the predispos- 
ing causes of that affection, etc.). It is now accepted 
that all pus-production in syphilis is the result of mixed 
infection, and that the staphylococci multiply in its sub- 
jects as at other times and in other persons. 

On the supervention of other typical disorders in 
those under the influence of syphilis, the result is con- 
ditioned upon the proportionate activity of the one or the 
other malady. Recently-infected syphilitic subjects ex- 
posed to typhoid fever speedily lose all symptoms of the 
original and exhibit all classical features of the later dis- 
ease, even to the date of a slow and apparently typical 
convalescence. On the re-establishment of the health the 
syphilitic affection, after an apparently absolute quies- 
cence for weeks, resumes its former activity, and the 
progress of the infective process seems to be resumed at 
the point where it was temporarily interrupted. 

Considering the number of both tuberculous and 
syphilitic subjects in large cities, it is a matter of 
great surprise that experts are so seldom confronted 
with the coincidence of the two affections in one indi- 



SYPHILIS OF THE SKIN. 73 

vidual ; the same may be said of syphilis and of carci- 
noma, though the different ages of the patients hable 
to display early symptoms of these two affections may 
here exert some influence upon the statistics. An 
attack of erysipelas has often cleared the skin of syphi- 
litic lesions, and, even when occurring in a patient whose 
luetic affection was grave, has emphasized the date of a 
recovery without further relapse. Indeed, of the larger 
number of all injuries and diseases occurring as acci- 
dents of the period when the subject of syphilis is dis- 
playing evidences of his disease, it may safely be 
asserted that they proceed to a conclusion which would 
have been anticipated if no systemic infection had 
existed. 

Syphilis of the Skin. 

In hereditary syphilis the bones or the viscera may 
first manifest the signs of the affection, since the new 
being is vitiated ab ovo. In acquired syphilis, on the 
contrary, the most obvious of the early lesions of the 
disease are perceptible in the skin and its underlying 
connective tissue and upon the mucous surfaces as well 
as in the superficial lymphatic glands and vessels. 

" Syphiloderma " is a term used to include many of 
these superficial lesions, the early eruptive and late infil- 
trations and deposits being termed " syphilodermata," 
or, as the term has been anglicized since its first 
employment by the French, syphilides. The word 
" syphiloma " is generally restricted to (late) gummatous 
deposits in the several organs of the body, not merely 
in the skin, but also in the bones and the viscera. 

The study of the eruptive symptoms in syphilis is of 
the very greatest importance not only for the expert, 



74 SYPHILIS AND THE VENEREAL DISEASES. 

but also for him who aims to be an accurate diagnos- 
tician in any department of medicine. He who cannot 
properly interpret these significant symptoms is usually 
not merely an ignorant but an unsafe practitioner. The 
peace of families, the conservation of the marriage 
relation between husband and wife, the reputation of an 
innocent girl, and the health of uninfected men, women, 
and children may all be hazarded by the decision of a 
single case. 

General Features and Relations of the Syphiloder- 
mata. — Syphilis may invade every organ of the body ; 
it may also involve any portion of the skin. As the 
chancre may be situated on any part, so the syphilo- 
derm may develop upon any given point of the bodily 
surface. As it has been seen that the chancre may be 
represented by every one of the several elementary and 
consecutive lesions of the skin, so the syphilodermata 
may develop in each of several forms — as a macule, a 
papule, a tubercle, a pustule, a bleb, or a tumor — and 
may betray such consecutive lesions as scales, crusts, 
ulcers, rhagades, fissures, and scars. A study of the 
syphilodermata is, in fact, a study of the changes 
impressed by the infective process upon the simple 
manifestations of all skin diseases. A syphiloderm may 
resemble an acne, a psoriasis, a seborrhoea, and even the 
skin-picture in variola. To determine with certainty that 
an eruption is syphilitic it is essential that the several 
modifications of lesions produced by syphilis of the skin 
be recognized fully. The actual result in any case is a 
composite of the ordinary pathological processes of 
congestion, inflammation, infarction of vessel, cell- 
multiplication, and secretory changes awakened in the 
tissues, which in all diseases resent these processes. 



SYPHILIS OF THE SKIN. 75 

Characteristics of the Syphilodermata. — Symmetry. 
— Many disorders of the skin attended with eruptions 
exhibit symmetrically-arranged lesions, such as variola, 
the medicamentous rashes, and purpura. In syphilis 
the earlier cutaneous symptoms are usually symmet- 
rical, but as the disease progresses the skin-lesions 
exhibit a greater tendency to asymmetry, until the 
latter becomes the rule rather than the exception. The 
macular syphiloderm of an early stage of syphilis 
usually displays this symmetrical arrangement in a 
marked degree. 

Color. — Too much significance has been attributed to 
the supposed characteristic color of the syphilodermata, 
though often the hue displayed by such lesions is like 
none other. It is important to bear in mind the obvious 
fact that the color of an eruption in a blonde and in a 
brunette subject, in an infant and in an aged person, in a 
region such as the face and in another such as the inner 
and superior aspect of the thigh, exhibits the widest 
contrasts. It is also true that in every person affected 
with a cutaneous efflorescence the color varies from 
hour to hour with the degree of congestion of the 
integument. 

In syphilis there is displayed no color which may not 
at times be recognized in non-syphilitic subjects; but 
the color with the other picture presented is usually 
highly suggestive. Its shades vary from a mixture of 
red, yellow, and brown to an empurpled hue, and they 
are rarely, if ever, commingled with the vivid and frank 
rosy tints of an erythema simplex occurring, for 
example, in a clear-skinned child, or the pure silver- 
white of the scales seen in lichen planus. The terms 
" copper-colored " and " raw-ham tint " have been 



"J^ SYPHILIS AND THE VENEREAL DISEASES. 

employed to designate the special hues of the syphilitic 
exanthem. The deepest shades of greenish-yellow, 
chocolate, and even black are often noted as sequences 
of the profound alterations occurring as the result of 
gummatous ulcers, particularly in the lower extremities. 

Polymorphism (Multiformity). — The frequency of 
the coexistence of several lesions of different types in 
one person and at one time is a characteristic of syphiHs 
shared by but few other maladies. It is not rare to find 
a subject of the affection first named exhibiting at a 
given moment condylomata about the anus, scaling 
patches in the palms, pustules upon the face, and 
papules of the thighs. 

Configuration. — The arrangement of the syphiloder- 
mata in groups or, after coalescence, in figures having 
the outline of a circle, either complete or in segments, 
is highly distinctive. Thus are formed odd-looking and 
characteristic groups of lesions in figures suggesting the 
shape of a horse-shoe, a kidney, the letter S, the figure 
8, and the arrangement of a brooch in oval or circular 
pattern with crescentic or circular " satellites " at its 
outer rim. The " serpiginous " feature of certain of the 
syphilodermata is the result of an evolution of lesions in 
similar lines spreading from one point of the skin to 
another in crescentic curves. This special configuration 
is probably associated with the distribution of the 
cutaneous nerves in definite areas. 

Absence of Subjective Sensations. — The absence of 
itching and pain in the great majority of syphilitic 
subjects displaying eruptive symptoms is a striking 
feature of the disease. The exceptions are, however, 
often well marked, a peculiarly sensitive individual 
suffering from pruritus even with macular lesions. It is 



SYPHILIS OF THE SKIN. 77 

also to be remembered that in a few special syphilitic 
lesions (particularly condylomata about the anus and 
the vulva, pustules upon the scalp, etc.) the itching may 
be extraordinarily severe, while the pain of a syphilitic 
ulcer may be excessive. It is none the less remarkable 
with how much toleration the average patient displays an 
abundant exanthem covering almost the entire surface of 
the body. Indeed, a careful physician is often the first 
to detect a syphilitic rash, the patient being wholly un- 
conscious of its existence until informed of the fact. 

Mode of Evolution. — The syphilodermata are de- 
veloped with remarkable indolence, and in some cases, 
especially in those neglected, they have a tendency to 
recur in different types, to be succeeded by others of a 
different character, and to undergo extreme metamor- 
phoses in situ, so that, for example, a papule may 
enlarge, flatten, ulcerate, or disappear and be succeeded 
by others pursuing the same or another course. It may 
well be doubted, however, whether this is so much a 
mode of evolution of syphilis as a variation of its evolu- 
tion due to the accidents of environment. Syphilis is a 
disease of relatively chronic type, and it is peculiarly 
subject to changes induced by improvement in the 
general health of the patient or the reverse, and in favor- 
able cases by treatment. 

Situatiojt. — Every portion of the bodily surface may 
be the seat of a syphiloderm, but in different localities 
there is usually seen a different expression of these local 
manifestations. Those of pustular type are often seen 
upon the scalp and on the face ; papules often appear 
over the neck and the brow ; secreting lesions, about the 
mucous outlets of the body ; scaling patches, on the 
palms of the hands, etc. 



y^ SYPHILIS AND THE VENEREAL DLSEASES. 

Peculiarities of Elementary and Consecutive Lesions. — 
Papules are ever predominant lesions of an average 
syphilitic history. They are usually characteristically 
ham-colored, and in exposed situations' they have a 
tendency to scale at the apex, to provide themselves 
around the border with a collarette of dirty-tinted scales, 
and in others to flatten into broad plaques, to crust, and 
even to ulcerate. 

Tubercles are also common in syphilis, and they are 
usually grouped. Their color and their frequent tend- 
ency to ulcerate and crust distinguish them from the 
much more indolent tubercles of lupus and lepra. 

The crusts of syphilis are usually bulky; they vary in 
color from a dirty greenish-brown to a dead black. 
When of rupioid type they are made up of laminated 
concretions like the shell of the oyster, this feature being 
produced by the concretion of pus and other inflam- 
matory products upon a secreting ulcer, which, as it 
spreads beneath, furnishes continually a broader base 
for the conical crust with which it is capped. 

Scales in syphilitic subjects are usually thin, are 
rarely very profuse or adherent, and are of a dirty- 
whitish hue. They never exhibit the nacreous shade 
of the psoriasic skin, nor, as heretofore shown, the 
silvery sheen of the scales in lichen planus. As dis- 
tinguished from similar conditions in non-syphilitic dis- 
ease, they are rarely the sole lesions present, but are 
more often complications or appendages of other lesions, 
as, for example, when they crown the apex of syphilitic 
papules or surround their base, or, as in the palm or the 
sole, when they furnish a ragged fringe encircling a dull- 
red patch either ulcerating or threatening such destruc- 
tive action. 



SYPHILIS OF THE SKIN. yg 

Ulcers in syphilis are usually characteristic. Their 
base is, as a rule, soft ; their edges are steep or under- 
mined and have a punched-out appearance ; their floor 
is covered with a foul pultaceous slough ; their secre- 
tion is purulent or haemorrhagic ; and their crusts are 
of the character described above. Often they are sur- 
sounded by an angry halo. Their outline commonly 
observes the several circular shapes already suggested, 
such as the arc of a circle, a horseshoe, a semilunar 
figure, etc. 

Scars left as relics of ulcerative and degenerative lesions 
are in syphilis usually pigmented when recent, but when 
old the pigment gradually disappears from centre to cir- 
cumference. In circular or oval contour they conform, 
for the most part, to the configuration of the ulcer or 
group of lesions that preceded their formation. When 
completely freed from their chocolate-tinted or violace- 
ous pigmentation they are of a dead-white shade, not 
greatly differing in this respect from scars in general, 
but they are, as a rule, much smoother, more superficial, 
less attached, and more elegant in delicacy of surface 
wrinkling than most other cicatrices. Their site is often 
of striking importance : as in syphilis, they are apt to be 
situated on the anterior face of the lower extremities (the 
leg particularly), though they may form in any portion 
of the body (face, arms, scalp, wrists, etc.). 

General Considerations relative to the Evolution, 
Involution, Variation in Type, and Accidental Feat- 
ures of the Syphilodermata. — The conception long 
held of the classical evolution of a syphilitic affection 
has to a great degree been modified by later observation 
and study. With reference to the syphilodermata, it 
was believed, and with some reason, that their evolution 



80 SYPHILIS AND THE VENEREAL DISEASES. 

was by a series of successive eruptions, the one in due 
course following the other, those of a so-called "second- 
ary" stage at first symmetrical and superficial, fading 
spontaneously and succeeded later by eruptions involv- 
ing a deeper structure of the skin. Thus papules were 
thought to follow macules, pustules taking the place 
of papules, until a late or so-called " tertiary " stage was 
in proper course reached, when the syphilodermata, no 
longer multiple and superficial, became fewer, deeper, 
isolated, and in various degrees destructive to the under- 
lying tissues. 

Such was the classical ideal ; but, as has been in part 
already shown, it was rather an artificial manikin for use 
in the schools than a pattern fashioned after observation 
of cases. If any such attack of syphilis has actually been 
observed, it was certainly an illustration of the very rare 
exception rather than of the rule. 

There are many facts which lead to the conviction 
that an attack of syphilis in a sound young subject 
whose case is perfectly managed throughout, with no 
intercurrent accidents to change its features, is a syphilis 
exhibiting a single exanthem. This eruption would be 
of the type of the superficial and symmetrical macular 
syphiloderm, after the disappearance of which as a result 
of vigorous treatment no other skin-lesions would appear. 
Persistent, faithful, and skilful management of the case 
subsequently should permit no further manifestations of 
the malady. This is, it must be admitted, a rare event, 
yet it is one that can be studied as an objective fact, and, 
rare though it be, it certainly is not so rare as the ideal 
case exhibiting in turn and in due course each of the 
syphilodermata in an ordered succession. 

The practical deductions from an acceptance of this 



SYPHILIS OF THE SKIN. 8 1 

new ideal are of importance. In the light of our present 
knowledge on the subject of micro-organisms and their 
role in the production of disease, it is clear that some of 
the syphilodermata are the result of mixed infection. 
Staphylococci are responsible for many, if not all, of the 
pustular lesions in syphilis. Again, it is capable of 
demonstration that many of the other syphilodermata 
are the fruit of local irritations, of errors in diet, in dress, 
in exposure, and in the habits of the patient. The 
impression that every eruption recognized in the subject 
of syphilis is due solely to that disease is so grossly 
misleading that it should carefully be excluded from all 
conceptions of the malady. The medicaments swal- 
lowed, the soaps employed, the articles of diet and drink 
consumed, play a significant part in many of the processes 
to be considered later. 

Again, it has been believed that the profuseness of a 
syphilitic eruption of early development bears some 
relation to the severity of the disease and to the ques- 
tions concerned in its prognosis. This is a conception 
based upon the old rather than upon the new ideal out- 
lined above. As a matter of fact, the first frank expres- 
sion of constitutional syphilis may be an abundant 
exanthem of macular type, extensively spread over the 
bodily surface, possibly sparing no area, and this may 
prove of better augury than one which feebly manifests 
itself and is too speedily followed by the symptoms of 
malignancy to be described later. Complete involution 
of an eruption of this character is often not followed 
by the evolution of a crop of small- or large-papular 
syphilodermata, nor, indeed, by any other eruption. 

Classification of the Syphilodermata. — The skin- 
lesions of syphilis are classified as follows : 

6 



SYPHILIS AND THE VENEREAL DISEASES. 



I. 


Macular. 


ia) Pigmentary. 
{f) Erythematous, 
(r) Purpuric. 


II. 


Papular, dry. 


ia) Miliary. 
{b) Lenticular, 




Papular, moist 


{a) Mucous patches 
[B) Condylomata. 


III. 


Pustular. 


(a) Miliary. 
{b) Lenticular. 


IV. 


Tubercular. 




V. 


Gummatous. 





The compound adjectives " pustulo - crustaceous," 
*' papulo-pustular," " gummato-ulcerative," and others 
are employed to express the frequent combinations of 
elementary and consecutive lesions to be recognized 
clinically in many cases of syphilis. 

In these pages all such terms as " syphilitic psoriasis," 
" syphilitic lupus," etc. are discarded. Combinations of 
syphilis with other diseases, however rare, are certainly 
never expressed in dermatological lesions, for an eczema 
(which certainly may occur in a syphilitic subject) is not 
a " syphilitic eczema," but is an eczema of unmodified 
type; and a scaling syphiloderm is never by any possi- 
bility a " syphilitic psoriasis," but is a squamous skin- 
lesion of the specific disorder present. 

I. Macular Syphilodermata. 
Pigmentary. — The pigmentary syphiloderm occurs 
without previous involvement of the skin, as a distinct 
network of pigmented, brownish, chocolate, or even 
blackish maculae, the hyper-pigmentation being con- 
spicuous by reason of contrast with the white and 
unaltered skin about each discolored spot. Gradually, 



SYPHILIS OF THE SKIN. 83 

and very slowly as a rule, the pigment is diminished in 
the centre of each deposit, and there is formed a whitish 
central punctum from which the pigment is at last 
wholly removed. These colorations occur as uniform 
ill-defined shadings, as pea- to coin-sized spots, or as a 
reticular arrangement, one form often slowly passing 
into another as the pigment atrophy and hypertrophy 
progress side by side. The eruption is seen rather more 
often in women, and in them chiefly on the neck and 
shoulders, but it occurs also in men, and over the face, 
neck, and forearms. 

This condition is decidedly more often seen in 
brunettes than in blondes, in this particular sharing the 
lot of most of the achromias of the skin. It especially 
affects in both sexes the Chinese, Indians, and negroes 
who have contracted the disease. It was once supposed 
to be rare, but without question is more common than 
was believed. 

The eruption, if such it may be called, develops 
at any time after general syphilis is declared, but 
it is much more common in the earlier months of 
the malady. It is exceedingly indolent, persisting 
for months, and even in exceptional cases for years, 
being in but a slight degree amenable to specific treat- 
ment. Though thus persisting, the complete involution 
of the affection occurs without ulterior changes in the 
skin, which, as a result, does not become the seat of 
infiltration, of degeneration, nor of scaling. Indeed, it is 
probably more an indirect than a direct result of infec- 
tion, and is peculiar in that it is decidedly more com- 
mon not merely in those predisposed by individual 
characteristics to pigment anomalies, but also in the 
uncleanly and the neglected. Anatomically, it is found 



84 SYPHILIS AND THE VENEREAL DISEASES. 

that a chronic endothelial inflammation of the smaller 
cutaneous capillaries occurs, under the influence of which 
the red corpuscles gradually lose their coloring matters, 
while eventually an obliterating endarteritis chokes the 
vascular channels. In the portions where the pigment 
has apparently been removed the normal quantity of 
coloring matter has at times been recognized; in other 
cases a true vitiliginous atrophy of the pigment has fol- 
lowed. It is highly probable that all these changes are 
under the immediate influence of the trophic nerves. 

The pigmentary syphilide should not be confounded 
with tinea versicolor, which develops often on the neck 
and the breast, for in the disease last named not only is 
a fungus visible under the microscope, but the fawn- 
colored patches are usually the seat of a fine furfura- 
ceous desquamation, readily recognized when the finger- 
nail is employed as a curette over the surface. The 
several chloasmata of other sources are, however, to be 
differentiated with care. Many of them appear on the 
face, and not elsewhere (the reverse of what is usual in 
the pigmentary syphiloderm). Vitiligo or leucoderma 
occurs often on the scalp as well as over the body and 
the face. Its disks are far more extensive than those of 
the syphiloderm, being often palm-sized and larger, and 
when occurring upon the scalp the hairs which spring 
from the achromatous patch are commonly white. In 
any doubtful case the symptoms of syphilis, usually 
declared by other signs in the event of a syphiloderm, 
should decide the diagnosis. 

Circumscribed pigmentations of the skin in syphilis, 
and even of syphilitic lesions themselves, differ in a 
marked degree from the pigmentary syphiloderm, since 
all the former are, without exception, sequences of some 



SYPHILIS OF THE SKIN. 85 

other disturbance (relics of a papular or tubercular 
syphiloderm, ulceration and cicatrization of gummata, 
especially in the lower extremities, etc.). 

The Erythematous Syphiloderm (" Syphilitic rose- 
ola," ** Syphilitic erythema"). — It has already been 
shown that there are grounds for believing that syphilis 
in an ideal case, occurring in a strong and healthy 
young subject, well managed throughout the entire 
career of the disease, would probably have but one 
cutaneous expression. That expression would be the 
erythematous syphiloderm. If syphilis be in type a 
disease of but a single efflorescence, the eruption here 
designated represents that exanthem. It is the most 
common, the most frequent, the most benign, the earliest, 
and the most classical of the skin-symptoms of the disease, 
to be expected in the great majority of all patients, and 
rarely failing to appear when awaited and searched for by 
the eye of the trained physician. It is also in syphilis the 
exanthem most often overlooked, as it may be limited to 
regions covered by the clothing, and is for the most part 
unaccompanied by any subjective sensation such as itch- 
ing. Women, especially those who are fleshy, when 
viewing its blush often suppose themselves to have been 
simply "overheated," and men, especially those inured to 
work in heavy flannels, look upon its lesions with no 
anxiety. It it often first demonstrated by the physician 
engaged in examining a patient for the detection of the 
character of a chancre. 

The exanthem usually first appears between the 
sixth and the seventh week after the appearance of 
the chancre, and with exceedingly insidious onset, so 
that on the very first inspection only a few delicately- 
tinted spots occur on the surface of the belly; and in 



85 SYPHILIS AND THE VENEREAL DISEASES. 

some cases, especially after indulging in a Turkish bath, 
a dance, or a generous dinner with wine, its lesions may 
be evolved with surprising rapidity. 

The faintest expression of this syphiloderm can scarcely 
be described. It resembles to a degree the delicate mar- 
bling produced when the skin of a healthy person is ex- 
posed to cool air after immersion in a hot bath. When 
well defined, the spots appear as multiple, oval-shaped 
or rounded, irregularly-defined macules, neither elevated 
above nor depressed below the general level of the integu- 
ment, having a diameter of from one-tenth to one- fourth 
of an inch. Their color varies in different skins and at 
different stages of evolution of the exanthem, being 
rarely of a pure rose or a vivid pink, but rather of a dull 
shade of yellowish-red, sometimes having an empurpled 
tint, at times so light as almost to suggest a simple 
erythema. The color fades under pressure of the finger, 
but later persists, and when further development of the 
exanthem occurs the maculations furnish a slight eleva- 
tion of the surface at each point of hypersemia — a condi- 
tion approximating that in which papular lesions appear. 
On complete involution, which often occurs without the 
sequel of another exanthem of the disease, there may 
be left transitory discolorations or lightly-pigmented 
macules persisting for several weeks. As a rule, under 
appropriate treatment the eruption fades, without the 
production of desquamation or other consecutive lesions, 
in the course of from a week to ten days, though occa- 
sionally it persists for several weeks. 

The abdominal surface and the chest, both anterior 
and posterior, generally display the exanthem in great- 
est profusion, but it is also encountered in vivid efflores- 
cence over the extremities, the face, the neck, and. 



SYPHILIS OF THE SKIN. 8/ 

indeed, over all the bodily surface. When distinctly 
evolved over the anterior surface of the belly and the 
back, it is often supposed by inexperienced observers to 
be strictly limited to these regions, but in almost all 
cases a careful search will reveal a faint mottling about 
the outer angles of the lips, in the palms of the hands, 
over the brows, and elsewhere. It is most brilliantly 
displayed on the abdominal surface when faintly seen 
elsewhere, chiefly because of the warmth and clothing 
of that portion of the body. In some cases it will be 
seen on close inspection that the arrangement of the 
macules is in generally circular outlines. 

The eruption which represents the transition between 
that just described and the papular syphiloderm is 
termed the " maculo-papular." Its peculiarities are 
briefly those, in varying proportions, of the two primary 
lesions from which it has its name. The variations 
between these eruptive forms, macules and papules, are 
numerous and interesting. 

In an exceedingly common variety the macular rash 
exhibits here and there, often with wide intervals of 
space, a few isolated papules, usually of the larger or 
lenticular type, scattered with seeming irregularity over 
the eruptive field, and springing usually from maculae. 
They have a dull-reddish tint, and they often scale 
slightly over the flattish summit or at the base. These 
may be sparsely distributed over one region of the 
body ; or when the trunk, for example, exhibits macules 
in wellnigh pure type, the lower extremities, where 
there has been some friction and usually also effects 
of gravitation, display these papules seated on an ery- 
thematous base. In yet other cases the papules are of 
miliary type and spring in large numbers directly from 



88 SYPHILIS AND THE VENEREAL DISEASES. 

the erythematous spots, till each of the latter is thus 
surmounted apparently by a small elevation. Here 
again the circinate arrangement may be conspicuous. 
In other cases the mouths of the orifices of the 
pilosebaceous crypts are the seat of the disorder ; in 
others the scalp becomes the site of a seborrhoeal flux, 
the secretion drying into light crusts superimposed upon 
a macular exanthem, the color of the latter often being 
displayed beyond the border of the incrustation. 

The macular syphiloderm may relapse under ineffi- 
cient treatment in one or several efflorescences, but, as a 
rule, it appears in typical development but once in a 
syphilitic history. The evolution of what is often thought 
to be a late macular syphiloderm, occurring two and 
more years after infection, is an eruption which has 
erroneously been supposed to be due to syphilis. In 
these supposed " late " cases there is developed over the 
surface of the chest, and at times on the belly and else- 
where, multiple, usually coin-sized, oval, elliptical, super- 
ficial patches, scaling very slightly at the periphery, and 
with a clear centre. They are usually brownish-red or 
purplish-red in hue; they have been noted as rebel- 
lious to the treatment indicated by the disease present 
Most of these are instances of pityriasis maculata et 
circinata, " pityriasis rosea " of authors. In the spring 
and the autumn many of the subjects of syphilis are 
peculiarly susceptible to this somewhat rare disorder, 
whose innocent lesions commonly disappear in a brief 
time under the influence of a tonic regimen, well com- 
bined with the use of the cinchona preparations and the 
salicylates. 

Purpuric. — Hemorrhage into the several portions 
of the integument occasionally complicates not merely 



SYPHILIS OF THE SKIN. 89 

the erythematous but also other syphilodermata, such 
as papules and bullae. In these cases the occurrence 
of pin-head and larger purplish and mulberry-shaded 
spots that refuse to disappear under pressure indicates 
that the coloring matters of the blood have been ef- 
fused through the tunics of the vessels. It is to be 
remembered, in all cases of syphilis where iodide of 
potassium has been administered for the relief of the 
disease, that this drug is capable of producing purpura 
of the skin, especially of the lower extremities. In 
some instances large disks and even wide areas of 
purpuric maculation are produced in both early and 
late periods of the disease. This symptom is, however, 
most commonly seen in the inherited forms of the dis- 
ease, though it is not rare in adults. When due directly 
to the disease, and not to a drug administered for its 
relief, it should be viewed as a somewhat grave symp- 
tom. It accompanies several of the paraplegic and 
hemiplegic complications of nervous syphilis. 

Anatomy. — Section of a macular lesion exhibits 
merely effusion between the component parts of the 
upper corium, with some displacement and elongation 
of the fibres of which it is composed. The capillaries 
are distended, and both within and without are encum- 
bered with cells. The accessory portions of the skin 
lying in the upper part of the corium (sebaceous and 
pilary crypts) participate somewhat in the process, but 
the sweat-glands in the deeper portion are unaffected 
(Crocker, Neumann, Biesiadecki, and others). 

Diagnosis. — The macular syphiloderm is distin- 
guished from the eruptions accompanying exanthema- 
tous fevers by the features described above, as also by 
the temperature-changes perceptible in such fevers. In 



90 SYPHILIS AND THE VENEREAL DISEASES. 

case of syphilitic fever other evidences of a systemic 
infection are commonly observed (adenopathy of the 
post-occipital and other glands; mucous patches of 
the mouth, anus, or vulva; alopecia; crusts upon the 
scalp, etc.). In the medicamentous rash due to copaiba 
there is commonly excessive itching ; this and other 
rashes due to drug-ingestion promptly disappear on the 
withdrawal of the exciting cause. In tinea versicolor 
the presence of the vegetable parasite and the distinct 
limitation of the eruption to the regions covered by the 
clothing are important points of difference. The color 
of the eruption — a very distinct fawn shade or deeper 
tint — never has the reddish-brown hue of the syphilo- 
derm. Pityriasis maculata et circinata is usually much 
less abundantly distributed, and its patches are always 
in ovals, commonly on the front and back of the chest 
and the shoulders, with scaling at the periphery of the 
clear centre, and displaying, when on the chest, an ar- 
rangement of patches with the long axis at right angles 
to the vertical line of the body. 

The prognosis of the macular syphilodermata is in 
general favorable, and no gravity need be argued from 
either their profuseness or their deep shade of color. 

II. Papules. 

It has been shown that papules are among the most 
common of the syphilodermata. Their grouping, color, 
situation, and environment in many cases of syphilis are 
so characteristic as to be absolutely diagnostic of the 
disease. They may appear at any time from the third 
month to the conclusion of the first year, and even much 
later ; they may develop in crops ; they may immediately 
spring from a preceding macular exanthem, or succeed 



SYPHTLrs OF THE SKIN. 9 1 

the latter after an interval ; and they are usually sym- 
metrical in the earlier and asymmetrical in the later of 
the periods named. They vary in size from a pin's head 
to that oj a bean, and may be multiple or {^\sf, dis- 
seminate or grouped, generalized or limited to distinct 
regions of the body, conical or flat, dry or moist, in 
color shading from a light crimson to a dull copper. 
They may scale at the apex or be surrounded by a col- 
larette of scales at the base. 

Papules represent the syphilitic process in the skin 
and the mucous membranes, beginning with an indolent 
inflammatory process in the corium, inducing a thicken- 
ing of the rete, some effusion of lymph-cells, and a break- 
ing away of the horny layers of the epidermis from the 
summit of the circumscribed inflammatory product 
where the thickening of the skin occurs. As this 
change may involve different regions of the body, gross 
results are obtained, whose differences depend largely 
upon the site of each lesion. Papules upon the scalp, 
for example, are usually dry and scaly ; when picked or 
scratched they often bleed and crust. Upon the exposed 
and dry surface of the skin, such as the extensor faces 
of the extremities, they are usually acuminate, dry, and 
squamous. On the brow, near the border of the hairs 
of the scalp, they often surround themselves with a deli- 
cate collarette of dirty scales, exposing a copper-tinted 
integument beneath and around the individual papules, 
the group being so characteristic as to have gained the 
title of the " corona veneris." 

When papules form upon apposed surfaces, such as the 
skin covering the voluminous breasts falling over the 
thorax in women, or the folds of the nates in contact, or the 
scrotum lying next the integument of the thigh, papules 



92 SYPHILIS AND THE VENEREAL DISEASES. 

enlarge, flatten, secrete, and in many cases produce a 
sensation of itching. Papules forming upon mucous sur- 
faces also, by reason of the heat, moisture, and friction 
to which they are subjected, become flattened and 
secrete, forming thus the mucous patch. Papules de- 
veloping upon or beneath the thick epidermis of the 
palms and the soles of adults are so bound down that 
they rarely rise above the general level, but the cracking 
of the scarf-skin at the level of the thickened subepi- 
dermic focus produces a characteristic scaling of the 
skin in the regions named. 

Dry Papules. — (a) Miliary Papjiles. — ^This abundant 
efflorescence is less frequently noted than other of the 
papular syphilodermata, for the reason that its very pro- 
fuseness argues a neglected or ignored condition of the 
subject of the disease in its prior manifestations. Since 
these neglected and ignored patients are often women, 
the eruption is somewhat more often observed in 
them. The lesions are pin-head-sized, closely-com- 
mingled papules, symmetrically arranged, often widely 
dispersed, and even generalized, at times distinctly and 
even elegantly grouped in circles or segments of circles, 
light reddish to deep crimson in shade, the apex of each 
papule at times surmounted by a still finer vesicle con- 
taining a droplet of serum — an accident which usually 
points to a coincident febrile access. Involution occurs 
by fine scaling at the apex of each lesion and flattening 
of the papules to a dull, purplish-red maculation of the 
surface. In rare cases, chiefly of public patients, this 
eruption may be merely the preliminary stage of a 
diffuse pustular syphiloderm. At times it can be seen 
that the lesions are limited to the hair-follicles. There 
are few cases in which, when the eruption is at all well 



SYPHILIS. 




Small papular syphiloderm (Stelwagon). 



SYPHILIS OF THE SKIN. 93 

marked over the face, the neck, and the trunk, groups 
of much larger lesions, to be described below, may not 
be seen in other regions of the body. 

Diagnosis. — The coincident symptoms (mucous patches, 
adenopathy, etc.) indicating the presence of a disease 
accompanied by other than skin-involvement usually 
suffice for the establishment of a diagnosis in these cases. 
Scabies and ringworm, the former due to an animal and 
the latter to a vegetable parasite, are distinguished by the 
presence of the exciting cause in each affection, the for- 
mer being, as a rule, accompanied by an intense and 
characteristic pruritus, the latter by a circinate arrange- 
ment of the patches. The lesions of lichen planus are 
flattened at the summit and usually exhibit polygonal 
outlines, while the frequent linear and angular distribu- 
tion of the papules is never seen in the syphiloderm. 
Psoriasis in some cases strongly resembles a scaling and 
well-developed papular syphiloderm, but the former dis- 
ease is, as a rule, more extensive, and the scales are more 
abundant, more voluminous, and more lustrous. Kera- 
tosis pilaris in extreme expression over the limbs and 
the body is to be recognized by the obvious situation 
of each papular lesion at the orifice of the pilosebaceous 
crypt. 

Prognosis. — The course of the eruption in healthy sub- 
jects, whether acutely or slowly pursued, is toward a 
favorable termination. At times the eruption proves 
intractable to treatment. 

{B) Lenticular Papules. — The papules are here usually 
discrete, rounded or oval in contour, and vary in size from 
a pinhead to that of a large bean and even larger. They 
are rarely elevated to any extent above the level of the 
integument, and at times they are so flat as to be mis- 



94 SYPHILIS AND THE VENEREAL DISEASES. 

taken for mere unsightly blotches of the surface. They 
vary in color from an exceedingly dull to a bright copper 
shade, and are usually remarkable for the fringe or col- 
larette of dirty scales fraying away from their base, as 
described in connection with the " corona veneris." The 
eruption may appear in a few months after infection, and 
then disappear, or it may occur in crops lasting, with 
varying intervals, for one or two years after the onset of 
the disease. These papules are among the commonest 
of the syphilodermata, and, with variations of the sort 
described above as due to the accidents of site and 
environment, probably figure in a modified form in most 
of the lesions which are to be observed during the first 
two years after infection. The eruption spreads both by 
the outcropping of new lesions and by the enlargement 
of individual papules in situ^ the latter being rather more 
common. As resolution occurs the papule flattens to 
the level of the skin, leaving merely a pigmented macule 
as a relic of its existence. These pigmented patches, 
especially over the face, are apt to be exceedingly re- 
bellious to treatment and slow to disappear, much to the 
chagrin of the patient, who speedily comes to a realiza- 
tion of their peculiar significance. 

The eruption may be quite general at the first, and 
later may limit itself to a favorite locality, such as the 
forehead, the back of the neck, the belly, the buttocks, 
the flexor aspects of the joints, the scrotum, and the 
outer face of the labia majora. 

It is the modification by grouping and coalescence of 
the papular syphiloderm that produces the sub-varieties 
recognized by authors as "nummular" and " corymbi- 
form." In the former the papules enlarge to flat disks 
of the size of large, and even of the largest, coins, cir- 



SYPHILIS OF THE SKIN. 95 

cumscribed, and with depressed crateriform centres, the 
contrast between the central area and the circumvalla- 
tion of the smooth, copper-tinted ring being conspicu- 
ous. In the corymbiform arrangement sateUite-hke 
groups develop about the central disk. Other odd- 
looking forms are the result of different groupings of 
the coalesced or isolated papules, as in the shape of the 
letter S, of a kidney, etc. 

Midway between papules and purely squamous le- 
sions In syphilis stand the papulo-squamous syphilo- 
dermata, lesions in which the characteristically developed 
and situated papules of syphilis undergo a squamous 
transformation at the summit, where a little heap of 
dirty-looking, adherent, sometimes friable, but often cor- 
neous scales accumulates. This combination of scales 
and papules has been thought to resemble psoriasis, but 
the correspondence is rarely suggested to the trained 
eye, for the elevation of the lesions, the character of their 
scales, and the color of the dull-tinted papules on which 
they rest are significant. The circular outline of many 
of the confluent patches of the larger papulo-squamous 
disks and of psoriatic patches in general is often confus- 
ing, and yet the bulkier and dirty-looking scales of the 
syphiloderm, the dull, ham-colored patch in the centre 
of the circinate group, often slightly infiltrated or thick- 
ened, offer a strong contrast to the more vivid hues of 
psoriasis. The clear-tinted and uniformly spread scales 
of the psoriatic patch, its centre either evenly thatched 
with such scales or, if quite clear, showing only a slightly 
shaded and non-infiltrated epidermis, are also to be con- 
sidered in establishing a differential diagnosis. Over 
the face the papulo-squamous syphiloderm is often cov- 
ered with a mealy or granular mass of scales of a dirty 



96 SYPHILIS AND THE VENEREAL DISEASES. 

grayish hue, this character of the exuvium being due to 
admixture with a desiccated sebaceous product. 

Diagnosis. — The differences between psoriasis and 
syphiHtic papulo-squamous eruptions are of importance. 
It is only atypical manifestations of either disorder that 
are liable to be confounded. The reddish and bleeding 
surface left on removal of the scales from a psoriatic 
patch is never exactly reproduced in syphilis, and the 
localization of the former on the extensor surfaces of 
the extremities is never characteristic of the syphilitic 
exanthem. Seborrhoeic affections, particularly of the 
face, resemble the scaling papular syphiloderm in the 
matter of the greasy crust with which they are covered 
and the generally dirty aspect of the patch, but the cir- 
cinate contour of the syphiloderm, never seen in the sebor- 
rhoeic disorder (save in exceptional cases on the trunk), 
and the characteristic copper hue of the surface beneath 
the scales, sufficiently distinguish the syphilitic exanthem. 

In almost all the syphilitic patches resembling those 
of either psoriasis or seborrhoea the infiltration of the 
body of the patch, with its higher wall of infiltration at 
the periphery, is evident on examination. 

Palmar and Plantar Syphilodermata (Palmar and 
plantar " syphilitic psoriasis," etc.). — The papules of 
syphilis, when developing upon the palms and the 
soles, have, as already shown, not only a characteristic 
aspect and career, but are rarely to be confounded with 
other disorders. The peculiarity of the papule in this 
situation is that it is developed within and beneath 
the dense and voluminous corneous envelope of these 
regions, and hence fails to produce either a conical or 
flattened elevation above the surface ; it produces instead 
a circumscribed thickening of the skin, (Fig. i), which in 



SYPHILIS OF THE SKIN. gj 

the epidermal portions scales, and in extreme cases in- 
duces an ulceration in the region of each papular thick- 
ening. These eruptive symptoms are often early to 
appear, and sometimes they linger after years have 
elapsed as almost the sole symptoms of the disease. 
They are much more common than is generally believed 
in the early periods of the malady — that is, within three 
months after infection — being usually recognized in some 
form by the expert when they escape the attention of all 




Fig. I. — Palmar syphiloderm (after Keyes), 

others, even of the patient. They occur usually sym- 
metrically, involving both hands and feet, in the earlier 
manifestations, and asymmetrically in later stages, when 
either the feet alone or the hands alone, or even but one 
palm or one sole, is attacked. Instances are not very 
rare in which, with few other evidences of the disease, 
six and eight years after infection, a single palm exhibits 
a squamous syphiloderm, having displayed this symptom 
with slight variations for a series of years. In all the 
regions named the influence of the employment of the 
hands in labor is usually striking, the right hand being 
worse or solely involved in right-handed patients, and 
7 



I 



98 SYPHILIS AND THE VENEREAL DISEASES. 

the feet worse in those who stand or walk much in the 
day; but marked exceptions occur. 

In its simplest expression the epidermis of the region 
involved displays merely split-pea to lentil-sized dis- 
colorations productive of no sensation by which the 
patient is made conscious of their existence. The centre 
of the palm or the inner face of the instep is usually first 
affected, and the spots may be either discrete and with- 
out apparent order as to grouping, or develop in arcs of 
circles to be distinctly or dimly discerned. From these 
points they may spread to the dorsum of the hands and 
the feet, even over the dorsum of the digits, but in all 
such instances the extension from the palmar or plantar 
to the dorsal surface can be determined without effort. 
In this way the extension may be toward the interdigital 
spaces and the wrists and the ankles, the squamous 
process being in obvious relation with that first invad- 
ing the palmar or the plantar area. When the digits 
alone are involved, the flexor aspect is always chiefly 
implicated, and here, as also in the palms and the soles, 
the natural folds and furrows of the skin furnish often a 
special territory for the incursions of the malady. 

As the disease advances, both in time and in degree 
of involvement of the integument, the maculae, of a ham- 
red shade, furnish from the surface of each a slight 
exfoliation, which, as the disorder advances, becomes a 
true scaling, the epidermis being lifted away centrally, so 
as to produce about the morbid spot a dirty-looking, 
ragged fringe of epidermis. An advanced stage of the 
disease is that where, usually in consequence of manual 
labor, friction, and exposure of the hands to soil, water, 
or chemicals, fissures result ; these fissures make inef- 
fectual attempts at healing, forming a new and tender 



SYPHILIS OF THE SKIN. 99 

epidermis which floors over the crack in the skin, only 
in turn to give way and be supplanted by succeeding 
fissures and new formations of epidermis until a palmar 
or plantar ulcer or an ulcerated fissure is excavated, bor- 
dered by successive plateaux of newer or older skin, the 
outer edge being represented by large, partly-detached, 
and ragged flakes of epidermis whose angular indenta- 
tions or scallops roughly resemble the fracture of a pane 
of glass by a missile projected through its substance. 
Deeply ulcerated and exquisitely painful lesions of this 
class are more often palmar than plantar, by reason of 
the use of the hands in labor ; but the feet of those who 
toil in sewer-digging, road-making, etc. suffer to a 
similar extent. 

A variation of this eruption is termed the corneous 
syphiloderiJi, and its peculiarities are due to the accumu- 
lation at the site of each papule of a mass of horny cells, 
more or less friable, which may occasionally be dug out 
from their bed with the point of a pen-knife, or, being 
spontaneously thrown off, leave little shallow pits 
behind. 

Diagnosis. — Eczema of the hands and the feet usually 
involves the dorsum, or, if the sole or the palm at all, 
only by extension to the latter from the former region. 
Eczema limited to the palms and the soles does, how- 
ever, occur, but chiefly in adults whose organs are more 
or less continually immersed in water, especially water 
charged with mineral constituents. Patients of this 
class are usually dyers, laundresses, bar-keepers, or men 
engaged at soda-water fountains. The infiltrated areas 
of eczema are never well defined save in eczema mar- 
ginatum of this region ; the involvement of the skin is 
much more uniform ; there is apt to be pustulation and 



100 SYPHILIS AND THE VENEREAL DISEASES. 

vesiculation ; there is never, under any circumstances, 
ulceration, even when the eczematous fissures are most 
painful ; and the itching is apt to be well marked. 
Psoriasis is said to be in very rare cases limited to the 
palms and the soles, but these exceptions are so few as 
simply to prove the rule. In any doubtful case the dis- 
covery of psoriatic patches on the scalp, the sacrum, the 
elbows, or the knees would determine the question. It 
has been said that syphilis of the palms and the soles is 
ever accompanied by some unexpected lesion elsewhere, 
and it is often true that a mucous patch in the mouth or, 
in advanced cases, an undeveloped gumma of the leg 
will reward the careful explorer for his pains. 

Moist Papules. — (a) Mucous patches (Mucous plaques ; 
Plaques iiiuqueuses). — The patch which is seated upon the 
mucous membranes in syphilis is pathologically identi- 
cal with the mucous plaque or the moist papule of the 
skin. In both cases the papule — which in the palm or 
the sole fails to become elevated, but flattens to the point 
of exhibiting merely a scaling and plain macule — shows, 
in the regions of moisture, of friction or apposition of 
contiguous surfaces, and of heat, merely an oval or circu- 
lar, scarcely elevated lesion. Its summit either furnishes 
a mucoid secretion or displays a thin pellicle more or less 
firmly attached, representing a sodden epidermal plate 
not as yet loosened from its underlying attachments. 

Moist papules of the skin in syphilis occur in regions 
where the conditions are similar to those of mucous 
membranes with respect to heat, moisture, and the appo- 
sition of surfaces, as between the breasts of women, 
between the nates, in the axillae and the groins of fleshy 
persons, and in the interdigital spaces. Here the lesions 
form flattened disks, slightly elevated above the general 



SYPHILIS OF THE SKIN. 101 

level, covered with a whitish or grayish pellicle, often 
slightly depressed in the centre, and looking not unlike 
one of the varieties of the soft corn. At times they have 
a reddish tint. They are generally moist, secreting a thin 
mucus which in warm weather and in the uncleanly has 
a fetid odor. These lesions are decidedly more common 




Fig. 2. — Moist papules (after Miller). 



in women than in men, and in the young adult rather 
than in the middle-aged. Occasionally they develop 
into large vegetating masses ; at other times they ulcer- 
ate. Their secretion is highly contagious. There is no 
better illustration of the moist papule than the chancre 
of the mucous surface of the prepuce, which, having sur- 
vived until general symptoms of systemic disease occur, 
undergoes a characteristic transformation in situ into a 
moist papule. 

{b) Condylomata (Condylomata lata; Verruca acumi- 
nata ; Moist wart ; Venereal wart ; Ger. Spizen Warzen). 
— Condylomata are simply moist papules which undergo 
a hyperplastic metamorphosis in consequence of the 



I02 SYPHILIS AND THE VENEREAL DISEASES. 

extremely favorable circumstances under which they 
develop. Thus, a recently infected, young, fleshy pros- 
titute of the filthy class is exceedingly apt to dis- 
play lesions of this sort about the vulva and the peri- 
neum. There are two tolerably distinct types of this 
affection, namely, the flat condyloma and the pointed 
wart. Both occur in syphilitic subjects, but the former 
is seen only in that disease and is a distinct symptom of 
it ; the latter is seen, when the conditions are favorable, 
not only in syphilis, but in other venereal diseases as 
well. 

Condylomata are found in the regions favorable to the 
growth of all moist papules, but they are best seen 
about the anus, where they often encircle the anal orifice 
with broad flattened disks from the size of coins to that 
of the section of a large ^%^. They enlarge by the 
growth of the primary lesions and also by coalescence 
of the disks. They have a disgusting odor, they generally 
secrete a mucoid or even a puriform semi-fluid, and they 
are whitish both from this secretion and from the pelli- 
cle covering their broad surface. They are capable of 
self-multiplication, the lying of one disk against an 
exposed surface being at times sufficient to produce a 
similar lesion exactly at the point of contact. As dis- 
tinguished from others of the syphilodermata, they are 
usually the seat of a tormenting pruritus. 

The pointed wart occurs in the subjects of syphilis 
and also in those whose parts are bathed with blennor- 
rhagic, leucorrhoeal, and other secretions not syphilitic. 
They are single, multiple, often exceedingly numerous, 
filiform, papilliform, or corymbiform, moist and pointed 
lesions varying in size from a pin-point to that of a fist, and 
even in extreme cases very much larger, the large-sized 



SYPHILIS OF THE SKIN. IO3 

masses being alv/ays compounded of many primary 
warts, the septa between which can be recognized divid- 
ing the compound mass into separate lobes. They are 
often smeared with mucus, after the removal of which 
can be seen their vivid red color, each separate apex being 
provided with a delicate tuft. They are often compared 
in appearance to the comb of a cock. They rarely 
occur in virgins, but at times they develop in pregnancy, 
disappearing, as a rule, after delivery. Cocci and bacilli 
have frequently been recognized upon their surface. 
They bleed readily and freely when torn, scraped, or 
wounded by accident. 

Pathologically, all moist papules are to be viewed as 
hyperplasias of the epidermis occurring under the influ- 
ence of the syphilitic process ; the pointed warts are not 
in all cases strictly defined syphilodermata, but are 
growths occurring under peculiarly favorable circum- 
stances in the situations described. These growths are 
impressed with the syphilitic mode when occurring in 
the syphilitic subject. Anatomically they are found to 
be built up chiefly of thickened and enlarged rete-cells, 
the corium and the papillary layer exhibiting cellular in- 
filtration, the papillae reaching upward by elongations 
between the wide fields of the mucous pegs dipping 
between the papillary eminences. 

Diagnosis. — Pemphigus vegetans (of Neumann) often 
occurs first about the vulva and the anus. Its lesions 
have frequently been mistaken for condylomata. Close 
study will, however, reveal that the vegetating masses in 
pemphigus spring from the sites of bullae, that they are, 
as a rule, more closely packed together, and that, instead 
of furnishing a mucoid secretion, they are bathed in a 
more profusely furnished fluid, which, as a rule, is desti- 



I04 SYPHILIS AND THE VENEREAL DISEASES. 

tute of any offensive odor. There is less flattening of 
the pemphigoid eminences; and when similar lesions 
occur in the mouth, the latter are to be distinguished 
from mucous patches by their extreme soreness and 
by the fact that in the latter situation they begin as 
blebs. In pemphigus vegetans there may be fever, and 
the signs of an exceedingly grave involvement of the 
system are usually present. 

III. Pustular Syphilodermata. 
It has been seen that the type of the lesion of syphilis 
in the skin is to be recognized in the papule. This may 
spring from a macular lesion or be such ab initio, but 
whether the one or the other, or whether the further 
evolution be in the line of the squamous syphiloderm 
of the palm or of the moist condyloma of the vulva, 
in all these cases the career of the syphilitic affection 
may be described as pursued within natural parallels. 
When, however, vesicles, pustules, or blebs appear, it 
may in general be believed that some accident has inter- 
vened to divert that career into singular channels. These 
accidents are, briefly, first, medicaments employed for 
the treatment of the disease, productive of medicament- 
ous rashes in the subject of syphilis ; second, the inva- 
sion of the skin by staphylococci (staphylococci pyo- 
genes albus et aureus) ; or, lastly, neglect or abuse of 
the skin, as in case of extreme filth, the application 
externally of injurious medicaments, and the attacks of 
animal parasites (fleas, bugs, lice, etc.). It is an inter- 
esting and noteworthy fact that the great number of all 
pustular eruptions in syphilis are observed in public and 
hospital patients. It is among the rarest of occurrences 
to find patients of the well-to-do class, properly treated, 



SYPHILIS OF THE SKIN. IO5 

exhibiting these symptoms of the disease. These erup- 
tions have, however, been so long classed with the 
exanthemata due exclusively to syphilis that some bold- 
ness is needed to relegate them strictly to the category 
in which they belong. They have, it is true, the syph- 
ilitic impress, but their exciting cause is an accidental, 
and not an essential, factor in the malady. 

Under the title of the pustular syphilodermata are 
here included all fluid-containing lesions of the skin, 
such as vesicles, pustules, and bullae. Many of these 
eruptive phenomena have been given unfortunate titles 
in the text-books, such as " varicella-form," " eczema- 
tous," " acne-form," etc. These names should all be 
obliterated from the nomenclature of syphilis ; first, 
because it is unwise to describe one disease in terms of 
another with which it is liable to be confounded ; sec- 
ond, because, to be of practical value in the way of 
description, a title should have a fixed meaning. The 
words " eczema," " impetigo," and " ecthyma," which 
have been used in this connection, no longer describe 
classically defined symptoms of any skin-anomaly, but 
mean, instead, ranges of widely differing symptoms due 
to various causes, and conveying to the eye no such fixed 
impression as these names are supposed to produce upon 
the mind. 

Miliary Pustular Syphiloderm. — In this eruption 
pinhead-sized pustules, or, more properly, vesico-pus- 
tules, are evolved, each at the summit of a papule, and, 
as previously suggested, almost always as the result of a 
febrile state complicating the ordinary evolution of the 
disease. At times the cause, however, as in the other 
eruptive disorders of this class, is distinctly due to a 
secondary infection with the toxines of staphylococci. 



I06 SYPHILIS AND THE VENEREAL DISEASES. 

The lesions are pinhead-sized, but they may increase 
to the size of the larger pustules. At times they have 
a circinate grouping ; at other times they are dissemi- 
nated freely over the face, the trunk, and the flexor 
surfaces of the limbs. In exceedingly rare cases the erup- 
tion is generalized. The pustules may be surrounded 
by a characteristically tinted areola, and they may dis- 
appear by desiccation of the effused fluid into thin 
brownish or dark-colored crusts, or there may be co- 
alescence of the pustules to the point of formation of a 
superficially suppurating surface. The firm, shot-like 
papules on the point of suppurating at the apex have at 
times been mistaken for the lesions of small-pox, which 
they greatly resemble. This syphiloderm is frequently 
recognized within the first few months after infection. 

It is somewhat difficult, and from a diagnostic point 
of view not highly important, to distinguish between 
the miliary and the lenticular pustules of syphilis, since 
the former are freely convertible into the latter, and the 
essential difference between all is merely the degree to 
which in each the minute abscess spreads in area and in 
depth. In the one class or the other are evolved the 
following clinical types : 

I. Pustules situated at the orifice of the pilosebaceous 
crypt, occurring chiefly where those accessories of the 
skin are largest and most abundant (scalp, face, and upper 
chest). In these regions minute or even large bean- 
sized, acuminate, and conical or flattened pustules form ; 
these pustules desiccate into thin crusts or furnish a 
superficial area of pustulation. The cicatrices left are 
rarely conspicuous or even permanent; more distressing 
to the patient is the brownish stain left. The lesions 
are often distinctly grouped. The general aspect of the 



SYPHILIS OF THE SKIN. IO7 

region thus involved (lips, nose, forehead, etc.) is one of 
extreme dirtiness, even the regions of the skin not dis- 
playing eruptive symptoms being unwholesome in 
appearance and muddy in hue. 

2. In a second clinical form the pustules are larger, 
usually flattish, and, after attaining the size of a pea or 
that of a large bean, surmount superficial, rarely very 
deep, circumscribed ulcers (Fig. 3). Here the pus- 
formation is decidedly more abundant; the copper- 




FiG. 3. — Large pustular syphiloderm (Stelwagon). 

colored or even chocolate-tinted pigmentation left after 
involution is more marked, and the resulting scars are 
more often indelible. 

3. In a confluent variety of the larger pustular lesions 
— as a rule, flattish and decidedly fewer in number than 
in other cases — there is distinct circular grouping of the 
pustules and the underlying ulcers. After fusion of the 
elements of the eruption an ulcerating ring forms, 
usually surmounted by a dirty-brownish crust, often 
with a ham-tinted stain at the outer border. Here heal- 
ing may occur at one or several points, producing thus 
alternations of crusts and newly-formed epidermis in the 
ring or the parts of a ring surrounding either an integ- 
ument unaffected centrally or a healed or healing ulcer. 



I08 SYPHILIS AND THE VENEREAL DISEASES. 

4. Another clinical form is to be recognized where the 
lesions are few and are not irregularly distributed over 
the entire surface, but where six or more form perhaps 
over the scalp, or a similar number along the alse of the 
nose, the extensor face of the elbow, or over the genital 
region, and perhaps none elsewhere. 

Pustulo-crustaceous or Pustulo -ulcerative Syphilo- 
dermata. — These terms represent an artificial distinction 
preserved, as a matter of convenience merely, in classi- 
fying the pustular syphilodermata. The lesions thus 
designated represent a variation in the line of ulcera- 
tion and consequent destruction of parts deeper than 
those affected in more superficial erosions (PI. 4). The 
pustulo-crustaceous syphilodermata are all pathologically 
alike, differing chiefly in point of gravity. Each repre- 
sents a secondary infection of the skin with cocci. Of 
the members of this group it may be said that the single 
or sparse lesions are commonly more destructive than 
those which are decidedly multiple ; that in point of 
gravity a very great multiplicity of lesions betokens a 
gravity dependent upon the constitutional effect of the 
involvement of a large portion of the skin in an ulcera- 
tive process ; and that generally the amelioration of the 
condition of the integument is proportioned to the im- 
provement in the systemic state of the patient. They 
represent in general a somewhat late stage of syphilis, and 
one in which are found patients who are cachectic, poorly 
fed, or improperly treated or cared for (PI. 5). Here the 
pustules tend to enlarge, to develop in more limited and 
circumscribed areas, to involve a greater depth of the 
corium and the subcutaneous tissue, and to be accom- 
panied by symptoms of malignancy. The area of each 
pustule or group of pustules assumes an angry look ; 



SYPHILIS. 



I'LATK 4. 




Pustulo-ulcerative syphiloderm, with survival of sclerosis of the peni 



SYPHILIS OF THE SKIN. IO9 

the pus formed is inspissated, hemorrhagic, and com- 
mingled with pultaceous sloughs ; the resulting crusts 
are blackish, the scars are persistent, and the pigmen- 
tation is deforming and slow to disappear. The ulcers 
left by the largest and most formidable of these lesions 
are of the type of the syphilitic ulcer in general. 
They have clean-cut, punched-out edges, a floor cov- 
ered with an adherent pus-bathed slough, an engorged 
base, and a roof at times constituted of the successive 
desiccations of pus formed from the spreading ulcer 
beneath, so that a stratified conical crust with limpet- 
shell aspect is produced. Here, again, the circular, 
semicircular, horseshoe-shaped, and other combinations 
of the circle so oddly characteristic of the ulcers of 
syphilis are constantl}^ encountered. 




Fig. 4. — Rupia (after Tilbury Fox). 

The oyster-shell-like crusts seen in various sizes in so 
many of the pustular syphilodermata, especially over 
large-sized lesions, were once supposed to be produced 
in other diseases, and the name rupia was given to the 
malady exhibiting these features. One of the axioms 
of the dermatology of to-day is that the symptoms of 



no SYPHILIS AND THE VENEREAL DISEASES. 

rupia are those of syphilis. Prior to the formation of 
these crusts there is always a history of, first, infection ; 
second, of the evolution of pustular or bullous lesions 
with hemorrhagic or semi-purulent contents ; third, of 
the bursting of the chambers containing these fluids; 
fourth, of their desiccation into greenish or greenish- 
black crusts, at first scarcely larger than a pea or a bean, 
later attaining the size even of a pullet's ^gg\ and, lastly, 
of a series of elevations of the stratified and conical 
crusts by successive accumulations from a constantly 
widening area beneath, until the picture of the rupioid 
skin is complete. When repair ensues the crusts fall, 
the ulcers granulate and become simple and shallower, 
and cicatrization concludes the history. Here, as so 
often seen in other of the syphilodermata, the under- 
lying ulcer may assume any of the circular outlines or 
the shapes of imperfect circles, the overspreading rupioid 
crust having a similar configuration. The exanthem is 
rarely generalized, though in extreme cases large areas 
of the trunk and the limbs may be involved, wide spaces 
of unaffected skin, however, usually intervening between 
the conspicuously contrasting crusts. The eruption 
occurs most frequently in the cachectic, the weak, and 
the victims of malnutrition, neglect, and poverty. In 
every instance, however, it indicates a secondary infec- 
tion with cocci. 

The other pustulo-ulcerative or pustulo-crustaceous 
syphilodermata are variants from the type represented in 
rupia, and most commonly in the direction of gravity- 
This is shown by such results as an increased depth of 
ulceration and more profound involvement and destruc- 
tion of tissue. Some originate as single or multiple 
vesico-bullae of apparently benign character ; some as 



SYPHILIS. 




Pustulo-ulcerative syphiloderm in a cachectic subject. 



SYPHILIS OF THE SKIN. Ill 

rapidly degenerate infiltrations which it is difficult to 
distinguish from gummata. All are apt to leave in- 
delible cicatrices ; yet, even after multiple ulcers o{ 
severe grade have riddled the integument in certain 
regions, the extent to which repair occurs and the evi- 
dences of damage are in the course of years smoothed 
away is, as a rule, surprising to those not familiar with 
these possibilities. 

Diagnosis. — From the several lesions described above, 
varicella and variola, however much resemblance may be 
traced between the former and either of the latter, may 
usually be distinguished by the fever of invasion, by the 
relatively active rather than indolent evolution of their 
lesions, by the umbilication of the fully-formed variolous 
vesico-pustule, and by the multiplicity of lesions in severe 
variolous cases, in which the lesions usually far outnum- 
ber the pustules of even the best-developed syphiloderm 
of the same type. Signs of syphilis other than pustular 
eruptions may be recognized in most patients affected 
with that disease, such as mucous patches, glandular 
involvement, alopecia, etc. In acne the usual limitation 
of the eruption to the regions of preference of that dis- 
ease (face, anterior and posterior aspects of the upper 
trunk) is generally suggestive, and the sprinkling of 
comedones among the pustules is significant. In syph- 
ilis, pustules of the face often appear in conjunction with 
similar lesions of the scalp ; this condition is practically 
never seen in simple acne, the scalp in the latter affec- 
tion being, when at all involved, the seat of either a 
seborrhoea or an alopecia furfuracea. Acne, however, is 
exceedingly common in syphilitic subjects, and it should 
always be recognized when complicating such cases. It 
occurs, first, as a result of ingested medicines, whether 



112 SYPHILIS AND THE VENEREAL DISEASES. 

properly or improperly administered for relief of the 
syphilis present (iodic or bromic acne) ; second, as the 
result of the causes efficient in the production of acne 
in the non-infected (alcoholism, dyspepsia, constipation, 
etc.). Hundreds of patients are annually treated for an 
ancient syphilis which has ceased to exhibit evidences 
of its existence and yet which is supposed to be in 
activity because of an unsightly acne. 

Pathology. — Under the microscope, sections of a pus- 
tular syphiloderm resemble very greatly those made in 
variolous and other disorders having similar lesions. 
The usual rents in the epidermis are visible ; its remain- 
ing strata are pus-infiltrated ; the deeper rete is eroded, 
in parts exposing the corium ; the individual elements 
of the latter are filled with lymph-cells ; the blood- 
vessels are distended, and in places are choked. Cham- 
bers originally filled with pus and the detritus 'c^f tissue 
are readily recognized at different levels, according to 
the depth of involvement of the tissue. Stretched and 
torn rete and corneous cells are visible both in the cavi- 
ties and in the walls of chambers formed by the exuded 
fluid. At times the site of the pustule is a hair- 
follicle, in which case its adnexa are also involved ; at 
other times the pus-making process attacks the corium 
outside the pilary and sebaceous pouches. Not merely 
the entire corium, but the subcutaneous tissue as well, 
may be involved (Cornil, Kaposi). 

IV. Tubercular Syphilodermata. 

Pathologically there is little difference between the 
tubercles and the gummata of syphilis, and even clin- 
ically the distinction between the two cannot always be 
determined. In many cases, however, it is a matter of 



SYPHILIS OF THE SKIN. II3 

convenience to distinguish between the classical forms 
of these frequent lesions. As a rule, the tubercle is 
more superficial than the gumma, occurs in less grave 
forms of the disease, is more apt to resolve and less dis- 
posed to degenerate, develops at an earlier period, is 
much more often multiple and exceedingly numerous, 
and occurs in a larger number of patients in forms that 
are grouped. 

Syphilitic tubercles may develop in the course of a 
few months after infection, but they are more common 
after the lapse of from two to ten years. They invade 
the face and the extremities, and in these situations and 
elsewhere (for they may be found in any region of the 
body) are pea-, split-pea- to bean-sized lesions, the 
smaller dimensions nam.ed being most frequently at- 
tained. They are firm, well-defined nodules, neither 
definitely flattened nor acuminate at the surface, with a 
tendency to assume the globoid shape. In color they are 
reddish-brown or copper-tinted, the hue deepening to a 
dark empurpled shade in the extremities by reason of 
gravity, and in the face after great congestion or 
unusual exertion, such as dancing. Their grouping is 
distinctively and characteristically in circles and por- 
tions of circles, further extension of the eruption being 
by the formation of new and adjacent rings producing 
the figure 8, the letter S, the dumb-bell, and the " satel- 
lites," as in the arrangement of a jeweller's brooch. As 
they differ in respect to the mode of their involution, 
they furnish thus a basis for a useful distinction. 

Resolutive ("Dry," ** Atrophic") Tubercular Syph- 
iloderm. — In this class are placed tubercular lesions 
which degenerate not by ulceration, but by resolu- 
tion through metamorphosis of the effused product 

8 



114 SYPHILIS AND THE VENEREAL DISEASES. 

beneath an unbroken epidermis. The result is unique 
— namely, the formation of a cicatrix where there has 
been no loss of continuity in the outer layer of the skin. 
The tubercles are then effaced by a species of atrophic 




Fig. 5. — Resolutive tubercular syphiloderm in groups. 

change, leaving a pigmented and cicatricial macule in 
the site of each tubercle, the pigment at a later date 
fading and leaving in its site conspicuous indented scars 
somewhat smaller than the original tubercle. These 
groups of scars, circumscribed and with their pigment 
but partially removed, forming portions of an imperfect 
circle, one arc of which is represented by tubercles as 
yet unresolved or but partially effaced, is one of the 
most striking of the pictures presented in syphilis, and 
one not imitated in any other disease. Upon the face 
(Fig. 5), about the knee, upon the elbow, or over the 
anterior aspect of the forearm in its lower third, these 
striking composite groups are always significant to the 



SYPHILIS OF THE SKIN. ri5 

trained eye. Tubercles of this class upon the palms and 
the soles are exceedingly apt to scale in process of either 
evolution or involution, the scaling being at both the 
summits and the sides of the lesions. The tubercles 
are in no way distinguishable from those described 
below, save in the matter of their historical career. 

Ulcerative Tubercular Syphiloderm. — In this arti- 
ficial class the tubercles degenerate by ulceration, this 
change occurring in different cases as a modification 
either of the elementary lesion itself or of the underly- 
ing tissues to which the ulcer, originally limited to the 
tubercular mass, eventually extends. In the simplest 
form these tubercles soften at the summit, exhibiting at 
this point a more or less adherent, slightly sloughy 
crust. If this crust be removed with more or less force 
at an early period, it can readily be seen that an ulcera- 
tive process has begun to destroy the upper portion of 
the small tumor. All the stages of ulceration and repair 
that follow depend upon the general condition of the 
patient and the good or bad treatment and hygienic aid 
which he receives. When the ulcer spreads beyond the 
mass of the elementary tubercle, it passes into the cate- 
gory of gummatous lesions ; but if the degeneration 
is limited to the original tubercle, the clinical picture is 
distinct. In these cases circlets, complete or partial, of 
crusted tubercles or of crust-covered and circumscribed 
ulcers surround an unaffected or infiltrated area of skin, 
the color of which is of the type seen in the resolutive 
groups described above. Upon the face, where these 
lesions are of special importance and of frequent occur- 
rence because of the exposure of this region of the 
body to frictional, accidental, and atmospheric influences, 
the arrangement may be less distinctively in circles; 



1 6 SYPHILIS AND THE VENEREAL DISEASES. 



as, for example, over the sides of the nose, where crusted 
nodules may be indiscriminately sprinkled over one or 
both sides with as little order as the lesions of acne 
with which this syphiloderm has at times been confused. 




Fig. 6. — Serpiginous tubercular syphiloderm (after Stelwagon). 

Upon the trunk and the limbs, however, the tubercles 
are often not merely grouped originally in circles or 
parts of circles, but they spread at times by serpiginous 
extension until wide areas have been swept over (Fig. 
6), leaving, where the activity of the process was once 
declared, broad, palm-sized and even much larger cicatri- 
cial patches where the skin is thinned, and where one can 
recognize the pea-sized and smaller, depressed and cir- 
cumscribed points, each representing the site of a former 
tubercle and ulcer. Often giant circles of involvement, 
affecting, for example, an entire buttock or a portion of 
the back, have in this way indolently progressed for 



SYPHILIS OF THE SKIN. WJ 

years, the nature of the disorder being misunderstood 
for that period. Many patients thus afflicted have been 
treated for years for " lupus," " tuberculosis," and other 
affections, relief having speedily been effected after dis- 
covery of the exact nature of the malady. 




Fig. 7. — Ulcerative tubercular syphiloderm (after Keyes). 

When tubercles of this class coalesce and degenerate, 
it is at times difficult to recognize the elementary lesion 
present. In these cases, obscure only to the inexpert, 
the encircling series of small tubercles is replaced by a 
rim-like wall of elevated tissue, either broken down at 
several points by the ulcerative process or preparing to 
break down. The area enclosed may also be found to 
consist of an infiltrated disk with circles or segments of 
circles within the parent group, some ulcerating at the 
outer border, others wholly or partially cicatrized in 
ineffectual attempts to ensure repair. Typical tuberculo- 
ulcerative patches (Fig. 7) strongly resemble many of 
the ulcerations following degeneration of gummata, and 
it is to be remembered that the process in each is 



\ 



Il8 SYPHILIS AND THE VENEREAL DISEASES. 

essentially the same, the differences being due solely 
to artificial classification. In all the grave and widely- 
diffused ulcerations springing from syphilitic tubercles, 
as a rule, the elements last named soon become incon- 
spicuous features of the general process. Repair of the 
degenerative losses here described occurs by granula- 
tion of the ulcers, by effacement and resolution of those 
not yet having undergone degeneration, and by the 
eventual production of multiple cicatrices, which, being 
often arranged in groups of circles adjacent to or encom- 
passed by others, furnish unmistakable evidence, years 
after the date of the development of the tubercles, of a 
syphilitic infection in the past. 

Diagnosis. — The diagnosis of a tubercular syphilo- 
derm, present or past, is of the very highest importance 
for the diagnostician, seeing that years may have elapsed 
after the date of infection before attention is attracted to 
the eruptive symptoms. Upon the diagnosis may rest 
a question of life or death, as, for example, when a man 
lies unconscious from a gummatous involvement of a 
portion of the meninges of the brain, and there is only 
a tell-tale scar on the buttock or the loin to indicate the 
original nature of his disorder. 

The papular and tubercular forms of acne, especially 
in florid-faced male subjects of alcoholism, occasionally 
resemble a tubercular syphiloderm of the nasal region ; 
but in syphilis there is usually complete failure of 
symmetry, one side of the nose being predominantly 
involved, though the exceptions are not rare. In acne 
the evident involvement of the sebaceous glands, the 
tortuous vessels visible about the lesions, and the general 
rosaceous appearance of the organ are characteristic. 
In syphilis, when at all advanced, there is either distinct 



SYPHILIS OF THE SKlN. 1 10 

crusting or superficial ulceration beneath the crusts, 
either of which signs suffices to distinguish the nature 
of the disease. 

The several forms of eczema are all recognized by 
their inflammatory aspect, their catarrhal features, the 
intense pruritus they awaken, and the general absence 
of distinct contour. The scales and the absence of 
scarring and ulceration in psoriasis usually suffice for 
its determination. Lupus vulgaris, one of the forms 
of cutaneous tuberculosis, is perhaps more often con- 
founded with syphilis, or the latter with the former, 
than are any confused diseases. The distinction is al- 
ways a matter of great importance. It must be borne 
in mind, when confronted with any doubtful case, first, 
that lupus vulgaris is a disease most often beginning in 
the first or the early part of the second decade of life, 
syphilis usually dating either from the latter part of the 
second decade or from that which follows it; second, 
that lupus vulgaris is decidedly less common than tuber- 
cular syphilis; third, that the latter is usually presented, 
in any doubtful case, at a period from three to eight or 
more years after the date of infection ; lastly, that, as 
regards chronicity, syphilis is a relatively rapid disease, 
producing in six months or less a destructive result which 
tuberculosis would require as many years to accomplish. 

The nodules of lupus are readily perforated with a 
blunt-pointed needle ; those of syphilis resist a firm 
impression. In lupus, even though a patch be formed, 
it distinctly lacks the ovoid or truly circular configura- 
tion assumed by groups of syphilitic tubercles, and it 
may be said never to produce the combinations of circles 
previously described. The same is true of the ulcers of 
lupus as distinguished from those of syphilis, the floors 



I20 SYPHILIS AND THE VENEREAL DISEASES. 

of syphilitic ulcers, further, being generally covered with 
a pultaceous slough surrounded by steep-walled edges, 
while the edges of the lupous ulcer are thin and stretch 
over softish, pulpy, jelly-like masses of indolent granu- 
lations. The degree of pain experienced is far greater 
in syphilis than in lupus. Over the face, lupus, whether 
destroying by absorption of the effused product or by 
ulceration, produces the characteristic " parrot's-beak " 
deformity of the nose or reduces it or the ear to a 
shrunken miniature of its former self; while syphilis 
boldly destroys one ala and at the same time spreads in 
the nasal fossae, attacking the bones of the nose and pro- 
ducing its special deformity by the sinking of the bridge. 
In tubercular syphilis of the face a circlet of lesions 
forming an infiltrated disk consisting of partly flattened 
and partly ulcerated tubercles is apt to attack one side 
of the brow near the root of the nose or to encircle one 
angle of the mouth ; while a lupous patch will involve 
rather the centre of one or of both cheeks, and will dis- 
play as many of its uniformly reddish-brown nodules 
in the enclosure as at the periphery of the patch. 

Epitheliomatous ulcers, of the face especially, are more 
readily distinguished from those of syphilis. They are 
often surrounded by characteristic "pearls" of cancerous 
growth ; they occur in a much older class of sub- 
jects ; their floors are smooth and glazed, rarely sloughy; 
their edges are strongly everted ; they are, as a rule, by 
no means painful ; and they observe a far slower evolu- 
tion, lasting for years without apparent change. 

It is to be remembered also that in all forms of sycosis 
the hair-follicles are primarily involved, and the disease 
is strictly limited to the region of the male beard ; that 
in leprosy the nodules of the face producing the leonine 



SYPHILIS OF THE SKIN. 



121 



aspect are never arranged in circles, but in ridges and 
rows along the brows, and have a characteristically var- 
nished appearance; that in rhinoscleroma — a disease 
reported in but a few isolated cases in America — there 
is a firm, ivory-like hardness to the portions of the nose 
involved that is not characteristic of syphilis ; and that 
in zoster of the face it is rare indeed that both sides are 
involved, there being usually a strict limitation to one 
side of the face of firm nodules just ready to develop 
into vesicles. 

V. Gummatous Syphiloderm. 
Gummata of the skin are circumscribed firm nodules, 
usually involving either the subcutaneous or the sub- 
mucous tissue, and often attacking later the underlying 




Fig. 8. — Gummata (after Jullien). 



structures, such as fascia, periosteum, bone, cartilage, 
and tendon. They vary in size from that of a small nut 
to that of an orange, and they are at first uncolored 
elevations of the skin, but later, when degeneration is 



122 SYPHILIS AND THE VENEREAL DISEASES. 

threatened, the integument over each nodule becomes 
purplish, livid, boggy, and thinned to a point where 
bursting of the contents of the gumma occurs through 
its connective-tissue envelope. Its name is derived from 
the gummy character of the product evacuated when 
bursting of the neoplasm ensues. When freely forming 
upon a level surface, gummata are usually globoid in 
contour, but they may be instead irregularly shaped 
and even flattened. They are rarely very numerous in 
one subject at a given time, many patients never exhibit- 
ing more than one, or at the most two or three, typical 
gummata (Fig. 8) ; in rare instances hundreds form at 
one time in the same person. 

Gummata are usually counted as " late " syphilitic 
lesions, but they may develop within a few months after 
infection. As a rule, however, from two to five years or 
more elapse between the date of the appearance of the 
chancre and their evolution. They may be the final 
evidences of the syphilitic process, or they may again 
and again return in the neighborhood of the first site of 
their appearance, until the skin and the underlying 
tissues are seamed with scars commingled with healing 
and unhealed nodules, and connected by bridges of ap- 
parently sound skin beneath which run sinuous channels 
of ulceration. 

At times the gummatous product is more or less 
widely diffused in a particular region of the body, such 
as the leg or the shoulder ; in these cases, especially if 
the disease has existed for some time, the appearance is, 
however characteristic of late syphilis, not always sug- 
gestive to the eye of its real character. In these in- 
stances large areas as broad as the hand, often with 
tolerably distinct demarcation, present an exceedingly 



SYPHILIS OF THE SKIN. 1 23 

irregular and confused surface, seamed with ridges, over- 
sprinkled with nodules and dense indurations, and per- 
forated here and there with ulcers. In extreme cases, 
where the nature of the disease has been wholly un- 
recognized for years and where intercurrent eczematous 
and other affections have complicated the process, a 
singular variation of type occurs ; and, especially where 
gravity has added its influence, as in the leg, there may 
be an elephantiasic result which requires careful scru- 
tiny for an accurate diagnosis. In these severe cases 
the nature of the disease can generally be recognized 
after study of a small portion of the invaded area, 
where, wellnigh hidden in a mass of tumefaction, a tell- 
tale scar or a circular ulcer with typical edge and floor 
reveals the truth. In another extreme type the entire 
gummatous tissue breaks down into a gigantic ulcer as 
large as or larger than a platter, with an indolent and 
sloughy floor, a circular outline, and an engorged base. 
As a consequence of the force of gravity, it is most 
common to discover these ulcerations on the leg, but 
they are seen also on the shoulders and on the back. 
When in the former situation, however extensive, they 
rarely completely girdle the ankle or the lower third of 
the leg, as may other ulcerative processes in this region, 
but a considerable portion of the skin, usually posterior 
in position, remains unaffected. Upon the face the 
destruction, if less extensive, is usually more hideous 
(Fig. 9). Here a gigantic excavation may result from 
the breaking down of gummatous infiltrations whereby 
the nasal and oral cavities are converted into one gaping 
chasm, as in the severe grades of epithelioma. A large 
portion of the pinna of one ear may slough. The bones 
of the face, skull, and jaws frequently suffer, and ectro- 



124 SYPHILIS AND THE VENEREAL DISEASES. 

pion, flattening of the nasal bridge, and extensive mutila- 
tion of the lips and the ears may ensue. 

Not the least conspicuous among the distinctive feat- 
ures of these severe ravages of syphilis is the extraordi- 




FiG 9. — Cicatrices resulting from extensive gummatous infiltration of the face. 

nary extent to which, when properly treated, repair 
ensues. When the general cachectic condition (evident 
in almost all this class of patients) yields to proper hy- 



SYPHILIS OF THE SKIN. 1 25 

gienic and medicinal treatment, cicatrization follows after 
even the most extensive and mutilating damage; the 
deformity is slowly smoothed away so as to escape rec- 
ognition save by the experienced eye, and the patient 
may enjoy a future life without return of the old trouble. 
In this way an obturator enables one man to close the 
gap between the mouth and the nasal cavity ; another, 
who has an opening connecting the oesophagus and the 
larynx, can in certain postures and by the aid of special 
devices swallow food without its access to the respiratory 
tract ; and even the most disfiguring scars of the face are 
slowly freed from pigment and diminished in circum- 
ference and irregularity until a degree of sightliness is 
produced (Fig. 9). It should not be forgotten, espe- 
cially in relatively young patients, that even with the 
worst accidents the recovery, under anything like fair 
treatment, will surpass the hopes of the most sanguine. 
It is in this respect that syphilis draws a sharp and 
significant distinction between itself and all other dis- 
eases productive of destructive effects — a distinction of 
the highest value with respect to diagnosis. 

Diagnosis. — The term "gumma" has lately been 
affixed to the somewhat similar cutaneous lesions of 
tuberculosis i^wy^ov^d., goinme scrofuleuse), and the resem- 
blance between these and the gummata of syphilis is not 
slight. In the former the recognition of other tuber- 
culous or scrofulous symptoms, their occurrence at an 
earlier period of life than most cases of syphilis, and the 
characteristic elevated longitudinal ribbons of empurpled 
and thinned skin, especially on the neck, enclosing depots 
of ill-conditioned pus, are common. When degenerat- 
ing, there are formed linear or narrow ulcers with 
thinned edges and pulpy floors covered with soft granu- 



126 SYPHILIS AND THE VENEREAL DISEASES. 

lations, the enlarged glands in the vicinity not yet being 
broken down. 

Sarcomatous tumors are usually multiple, occur in 
conditions where cachexia is more marked, and are, as a 
rule, slower of evolution than syphilitic gummata, 
though at times undergoing rapid changes. They are 
rarer in the lower extremities than elsewhere — a dis- 
tinguishing feature of gummata in syphilis. 

Lipomata are readily differentiated from gummata by 
the softness to the touch of the former and by the 
"pillowy" feel of the growths, which, furthermore, are 
usually of far longer duration without change than 
syphilitic tumors. From a gumma, epithelioma is at 
times distinguished with ease, at others with very great 
difficulty. The following points are to be remem- 
bered : Cancer, as a rule, occurs at a later period of life, 
but at times the gummatous changes in syphilis occur 
at the same age. In epithelioma of the skin the 
** pearls " or waxy nodules, scarcely larger than pin- 
heads of good size, are characteristic, and are never seen 
in syphilis. The course of an epithelioma of the skin 
is far slower than the career of a gumma, the latter 
rarely requiring more than a few months for its termina- 
tion either by resolution or by disintegration, while a 
cancer of the skin may endure with less destruction for 
a decade of years. Multiplicity is true of the syphilitic 
more often than of the cancerous ulcer. The edges of 
the specific ulcer are steep or undermined ; those of the 
epitheliomatous excavation are everted often to a very 
marked degree. In syphilitic ulcer the floor is sloughy 
or pus-bathed ; in cancer it is, when typical, covered 
with a thin, varnish-like secretion which scarcely conceals 
the florid and irregularly excavated surface beneath. 



SYPHILIS OF THE SKIN. 1 27 

Gummata of the progenital region are at times liable 
to be confounded with initial scleroses and chancroids, 
but the accompanying adenopathy of the latter, their 
relatively rapid career, and the greater extent of the 
infiltration of the gumma usually indicate the difference. 
The chancroid is always more distinctly purulent and 
less indurated than the gumma. 

Ulcers of the leg resulting from pressure-effects in 
the subjects of varicose veins of this region and of 
the thigh often present a strong resemblance to the 
ulcers of syphilis, but the distinction between the two 
can usually be made without difficulty. In the one case 
the enlarged veins, in the other the painful character of 
the trouble, the cedematous condition of the limb, the 
frequent coexistence of eczema, and the entire absence 
of a well-rounded scar or a deep circular ulcer, usually 
aid in the diagnosis. The picture in the non-specific 
disease is usually more serious than in the syphilitic 
disorder which it is sought to differentiate. The pig- 
mentation in long-standing cases is far deeper and 
blacker in shade in the varicose condition, in conse- 
quence of the extravasation of blood. A tolerably clear 
outline to any given patch of diseased skin, and an 
absolutely unaffected integument in close proximity to 
an ulcerated or engorged patch, point always in the 
direction of syphilis. 

Pathology. — Anatomically, the tubercle and the 
gumma of syphilis are practically identical. The 
process is essentially one of disintegration of the com- 
ponent parts of the nodule, with central fatty and puru- 
lent degeneration of fibres, cells, and nuclei, and pe- 
ripheral proliferation with round cells commingled with 
few giant-cells surrounded by connective-tissue fibres. 



128 SYPHILIS AND THE VENEREAL DISEASES. 

The zone of proliferation about the central depot of 
globules is evidently protective in character (Kaposi, 
Basset). 

The groups of syphilodermata described above are 
classified in the artificial divisions, between which they 
can, for the most part, readily be separated. There are, 
however, a few manifestations of syphilis in the skin, 
the peculiar features of which justify special considera- 
tion. They are, in point of fact, modifications of the 
symptoms already described. 

Serpiginous Syphiloderm. — The term "serpiginous" 
was originally employed, as its etymology suggests, 
to designate a lesion displaying '' creeping " features, 
a slow and gradual extension from one point or from 
several points to others on the cutaneous surface. At 
present the word designates the peculiarities which 
may be assumed by one or another of the syphiloder- 
mata, rather than any special exanthem of syphilis. 
In a serpiginous eruption there is extension of the dis- 
ease, either by ulceration or by retrograde metamor- 
phosis, at the periphery of an involved patch, while the 
central portion is the seat of partial or complete cicatri- 
zation. While this .effect may not rarely be noticed in 
any of the ulcerating or resolving syphilodermata in 
groups, the term "serpiginous" is applied specifically 
to those cases in which this peripheral extension and 
centric involution are decidedly more pronounced than 
other features of the disease at any time present. 

The serpiginous feature may be assumed, as has been 
seen, by a group either of pustules, tubercles, papules, or 
gummata. Beginning with one or a group of several of 
such lesions, the process may be either superficial or 



SYPHILIS OF THE SKIN. 129' 

deep. As a rule, the most ambulant and erratic of these 
serpiginous patches belong to the former rather than to 
the latter class. 

On the earliest recognition of a serpiginous tendency 
in any patch of disease, it can be seen that the clearly- 
defined peripheral wall is spreading either in equal radia- 
tions from a central point (artificially placed) or, rather 
more commonly, more actively in one direction than in 
any other. The peripheral wall may be built up either 
of confluent papules or tubercles or any crusted lesions 
of the types named, or by sequelae of any of the latter 
in the form of a shallow ulcer, circular in outline, re- 
sembling a moat about an enclosed field. The central 
area may then be made up of infiltrated integument, 
pigmented or otherwise discolored, or by small coin- 
sized cicatrices, or by partly-healed ulcers of smaller 
dimensions than the mother-lesion within which they 
are confined. As the environing circle with its wall and 
open or crusted ulcer widens, the central area proceeds 
to a more complete involution, leaving at last broad 
spaces often converted into a smooth scar-tissue, or a 
field in which the delicate creases and punctate markings 
suggest the action of the tool of the engrav^er on the 
surface. This odd-looking involvement of the integu- 
ment may be in progress for months and years, spread- 
ing from one or more primary points and gradually 
migrating over an entire thigh or abdomen, the patient 
meantime often displaying in other respects a marked 
degree of general health and vigor. 

When the action is deeper, the ulceration, invading the 
subcutaneous and even the deeper structures, usually 
begins with the disintegration of tubercle or gumma and 
spreads by extension, more often downward and deeply 



130 SYPHILIS AND THE VENEREAL DISEASES. 

rather than peripherally and at the superficies. In this 
way there are digged in the muscles, the fascia, and 
between the tendons, gigantic excavations each having 
usually the circular outline and the sloughy floor of the 
syphilitic ulcer, and exhibiting a marked tendency 
toward phagedena. Both superficial and deep forms 
of serpiginous ulceration occur for the most part in 
persons of a broken-down constitution ; they are, how- 
ever, encountered among the fleshy, the consumers of 
alcohol in excess, and those given to modes of life which 
in non-syphilitic subjects are specially favorable to the 
production of gout. They are exceedingly rare in 
young and sturdy subjects of the disease. 

Diagnosis. — The disease most likely to be con- 
founded with serpiginous forms of syphilis of the skin 
is a variety of chancroid to which, at times, the title 
" serpiginous chancroid " has been applied. In the 
latter affection the ulceration is most often subcutaneous 
in situation, spreading for years, at times insidiously, 
beneath bridles and bridges of apparently unaltered skin, 
often with enlarged glands in the vicinity, generally 
upward over the belly or downward over the inside of 
the thigh, almost never elsewhere. The history usually 
gives some clue to the solution of the problem. 

The vegetating forms of epithelioma are often exceed- 
ingly like the serpiginous syphiloderm, extending from 
a central area in verrucous growths at the periphery of 
a patch which has at times a well-rounded outline. In 
this event the adv^anced age of the patient, the absence 
of enclosed minor ulcers and cicatrices within the en- 
compassing ring, the extreme slowness of the process 
as contrasted with the extension of the syphilitic affec- 
tion, and the distinctly verrucous character of the growth 



SYPHILIS OF THE SKIN. I3I 

at the circumference of the patch, aid in estabhshing 
a diagnosis. Again, carcinomatous disease is decidedly 
more frequent on the face than elsewhere, while the 
largest of the syphilitic lesions are usually visible on 
the trunk or on the limbs. 

Tuberculosis of the skin (lupus vulgaris and other 
forms) is so very rarely encountered with truly serpigi- 
nous characters that one views with some distrust a 
diagnosis of " serpiginous lupus." In any such rare 
case the history of the disease, the age of the patient 
when first attacked, the characters of the ulceration, and 
the other distinguishing features of the lupoid ulcer 
given above, should suffice for the determination of its 
nature. 

The vegetating syphiloderm is another of the titles 
given, not to a special cutaneous lesion of syphilis, but 
to a feature which may be assumed by one or more of 
such lesions. In these cases there is a tendency to 
assume the papillomatous type, with hypertrophy of the 
epidermis and of the deeper portions of the skin. These 
hypertrophies usually occur as complications of the 
moist rather than of the dry lesions of syphilis in the 
skin, and they are of more frequent occurrence in 
regions where there is both unusual heat and moisture. 
They are also much more apt to develop in young and 
fleshy subjects of the disease, and particularly in young 
and fleshy women. 

In these cases wart-like and papillomatous vegeta- 
tions develop from either plane macules and irritated 
surfaces or from papules, pustules, condylomata, or 
ulcerating points. They vary in size from lenticular 
growths to masses as large as an orange and even much 
larger, usually secreting a foul-smelling puriform mucus 



132 SYPHILIS AND THE VENEREAL DISEASES. 

from the side, base, or summit of the vegetation. These 
growths are particularly liable to occur in the region of 
the scalp, about the folds of the axillae, the groins, and 
the nates, and about the anus. The rounded, flattened, 
acuminate, or tufted summits of these excrescences are 
usually covered with crusts due to the desiccation of the 
puriform secretion with which they are smeared, and on 
the removal of which the dull-reddish or florid surface 
of the masses can be distinguished. When removed 
artificially or spontaneously the superficial character of 
the process is readily determined. 

The diagnosis is from lupus, pemphigus vegetans, 
framboesia, yaws, and all the simple papillomatous and 
warty growths. The distinction between the skin- 
lesions of syphilis and the two diseases first enumerated 
has already been given. In framboesia there is always 
an absence of the other symptoms usually shown in 
patients with vegetating syphilodermata ; the subjects 
of the disease, further, are chiefly those either living on 
or recently leaving the coasts of Africa. The creamy 
secretion, the acid reaction, and the shorter career of 
yaws are all significant. The warty growths found on 
the scalp and elsewhere of persons not infected with 
syphilis often present features strongly resembling the 
vegetating lesions here described, and the distinction 
between them all is to be looked for in the peculiar cha- 
racters of the syphiloderm. In the latter, the size of the 
single or the abundance of the frequently multiple 
growths, the fetor of the secretion, and the accompany- 
ing symptoms of an infective disease are chiefly to be 
relied upon in the establishment of a diagnosis. 



SYPHILITIC AFFECTIONS OF THE HAIR. 1 33 

Syphilitic Affections of the Hair. 

The most important of the changes produced by 
syphih's in the hairs is an alopecia, important both 
because of the disfigurement it produces and because 
of the aid it furnishes in establishing a diagnosis of the 
disease. Syphilis, however, involves the nutrition of 
the hair often without production of an alopecia, work- 
ing in many subjects of the disease a special dryness 
and other symptoms of malnutrition without fall of the 
hair sufficient to be conspicuous. There are two well- 
differentiated forms of syphilitic alopecia : in the first 
form the loss of hair is due simply to the action of the 
virus of the disease, presumably upon the nerves of the 
scalp ; in a second form the alopecia is directly induced 
by changes in the scalp. 

Syphilitic Alopecia without Obvious Structural 
Chang"e in the Integument. — This is decidedly the 
most common form of the affection, exhibiting conspic- 
uous features in many patients, and probably occurring 
in an unobtrusive form in the great majority of all well- 
developed cases. It may coexist in the same person 
with an alopecia due to structural changes ; it may be 
partial or general, though the latter is of exceedingly 
rare occurrence ; and, as a rule, it develops among the 
earliest symptoms of systemic intoxication. At times 
only the hair of the scalp is affected ; at other times 
the scalp, brows, lids, axillae, and extremities are, in one 
or several regions, made partially bald. Usually the 
hairs of other regions are lost only when the scalp is 
involved, but at times when the scalp is unaffected the 
hairs of the brows or of the beard may fall. 

All grades of loss are perceptible, from that escaping 



134 SYPHILIS AND THE VENEREAL DISEASES.' 

casual observation to that in which the scalp is laid bare 
over wide areas, the hairs falling in large numbers, slight 
traction upon any filaments selected at once bringing 
them painlessly from their pouches. As a rule, the 
resulting deformity is manifested to the eye in a cha- 
racteristic '* raggedness " of the hirsute covering, bare 
patches being particularly noticeable over the temples 
and the occiput, as distinguished from the pre-senile 
losses often seen where the thinning is largely limited to 
the vertex. When, however, the scalp is shaved or the 
hairs are clipped close, it is clear that the loss occurs 
chiefly in finger-nail-sized areas, often closely set 
together, never producing the palm-sized, completely 
bald patches of most non-syphilitic diseases accom- 
panied by alopecia. Upon the eyebrows the loss is 
often highly conspicuous by reason of its lack of sym- 
metry, the hairs of one brow, for example, being 
removed when the other is intact, or one-half of the 
hairs falling from one or the other extremity of the brow 
of one side. The conspicuousness of these forms of 
alopecia makes them most offensive to the conscious 
subjects of the disease. When the loss involves the 
region of the male beard, the patches are usually similar 
to those seen on the shaven scalp ; but occasionally a 
baldness of the bearded face occurs in large patches 
which it is difficult to distinguish from alopecia areata. 
Syphilitic Alopecia due to Structural Changes in 
the Integ-ument. — In these cases the alopecia is con- 
secutive to the evolution of a syphiloderm in the region 
of the skin affected with the hair-loss. The pre-existing 
lesion in the best-marked cases is then of an ulcerative 
type, resulting in a destruction of tissue limited to the 
area where the loss of hair occurs ; in this event even 



SYPHILITIC AFFECTIONS OF THE HAIR. 1 35 

the baldness is often a minor symptom when compared 
with the graver metamorphoses of the skin in which 
the hairs were once implanted. Other syphilodermata 
may, however, be responsible for the alopecia, such as 
macular, papular, papulo-pustular, and tubercular lesions, 
as also gummata, the latter involving also the subcu- 
taneous structure. Most of these lesions are effec- 
tive by actual destruction of the hair-follicle by either 
ulcerative or resolutive changes following the syphilitic 
deposit. As compared with the simpler form of alopecia 
previously described, it is noticeable that the alopecia due 
to structural change in the skin is often remediless, while 
the former is almost invariably followed by a return of the 
hairs ; that the tissue-change is most often circumscribed 
and limited to a single region of the body, particularly 
the scalp; and that the alopecias of early syphilis, which 
are often multiple and unaccompanied by destructive 
changes, differ widely in every feature save the hair-loss 
from the invasions of the hair-sacs by the late, usually 
gummatous, deposits of the disease. When the milder 
forms of consecutive alopecia occur, they often result 
from a species of syphilitic involvement of the sebaceous 
glands of the scalp and of other regions, finger-nail- 
sized patches of the part involved being covered with 
fine, often greasy scales, the integument being manifestly 
hyperaemic and tinted in the dull-reddish hues of the 
syphilitic macule. 

Diagnosis. — In almost all forms of syphilitic alopecia 
the diagnosis is established by the discovery of other 
symptoms of the disease, which, as a rule, may be dis- 
covered if sought for with special care. It is, however, 
true that in exceptional cases the force of the first in- 
toxication of the system seems to expend itself wholly 



136 SYPHILIS AND THE VENEREAL DISEASES. 

upon the hirsute covering of the body, and in these 
losses it may be a matter of difficulty to discover the 
site of the original chancre and its possibly persistent 
underlying sclerosis. 

Alopecia areata most strongly resembles the syphi- 
litic form of baldness, but in the former the patches 
are usually large, the skin denuded of hairs is smooth 
and white, the line of demarcation after the few hairs 
that are loosened at the periphery have been epilated is 
much more distinctly outlined by vigorous filaments, 
and, seeing that children are not rarely affected, the sub- 
jects of the disease are at times much younger than 
those suffering from acquired syphilis. 

The congenital, pre-senile, and senile losses of hair 
are usually symmetrical and permanent; they occur at 
epochs of life which commonly contrast with the average 
age of acquisition of syphilis, the exception occurring in 
pre-senile forms of baldness, where there is usually a 
definite history of preceding seborrhoeic trouble. The 
simpler varieties of baldness are, however, of much 
longer duration than the common forms of syphilitic 
alopecia. In ringworm of the scalp the presence of the 
parasite and the tender age of the subject of the disease 
are significant. In psoriasis of the scalp the highly 
characteristic scale-accumulation, often extending beyond 
the confines of the scalp at the brow is a diagnostic 
feature. 

Syphilitic Affections op the Nail. 

It is usual to distinguish between two different forms 
of syphilitic invasion of the nail and its peripheral tissues, 
the term paroiiycJiia being employed to designate the 
changes in the nail-substance which are consecutive to 



SYPHILITIC AFFECTIONS OF THE NAIL. 1 37 

those occurring in the tissues about the nail ; while the 
term onychia is limited to changes occurring primarily, as 
regards obvious symptoms, in the nail itself. The two 
conditions may coexist. The distinction is, however, 
though useful for clinical purposes, scarcely based upon 
pathological facts, seeing that it is highly probable that 
no changes whatever occur in the nail proper prior to dis- 
turbances in the nervous or other structures with which 
it is in relation. 

Changes in the Tissues Surrounding the Nail, with 
or without Consecutive Lesions of the Latter (Par- 
onychia syphilitica). — In the more superficial variety of 
this disorder the epidermis and often the deeper portions 
of the skin in a circumscribed patch, usually at one ex- 
tremity of the nail-groove, thicken and assume a warty 
aspect. This local thickening may be resolved in suc- 
cessive exfoliations with some resulting tenderness, or 
there may be superficial excoriations, fissures, or even 
resulting ulcers. One or several digits may be involved, 
the fingers more often than the toes, on account of the 
exposure of the former in the occupations of life. Some- 
times the integument of one or several joints of the digit 
is implicated in the process. This complication occurs 
within a few months after infection, or it may be delayed 
to one or two years after — rarely the latter. It is most 
often contemporaneous with maculo-papular and papulo- 
squamous lesions of other regions. The consecutive 
changes in the nail, when such occur, are of the milder 
types elsewhere described. 

In a deeper form of involvement of the tissues about 
the nail, a nodule, dull ham-tinted and tender, varying 
in size from that of a pea to that of a bean, forms either 
in the nail-fold, the nail-groove, or the matrix, usually 



138 SYPHILIS AND THE VENEREAL DISEASES. 

Upon one side. Occasionally the more prominent skin- 
symptom is a deep and ill-defined infiltration. The 
cracking and exfoliation seen in the superficial form 
may be conspicuous in the deeper form of the disease, 
the infiltration undergoing in favorable cases complete 
resolution under appropriate treatment, though its course 
is commonly indolent. In other cases ulceration ensues, 
the part becomes tender, at times exceedingly painful, 
and the pus which may be discharged gives no such 
relief as in the " run-around," the course of which is much 
more brief The affection persistently lingers when the 
toes are involved. The odor of the secretions furnished, 
especially by the great toe, which on account of its 
prominence often suffers, is, as usual in this region, 
often highly offensive. 

Ulceration, whether resulting from the superficial or 
the deeper involvement of the parts about the nail, 
occurs as a complication of both processes in various 
grades. The course of such complications is always 
modified by treatment. As usual, the fingers and the 
great toe, for reasons already explained, suffer more 
than the other digits. 

The ulcer, whether starting from nail-fold or matrix, 
assumes, as a rule, with startling rapidity its formid- 
able features. The edges of the ulcer are raised, often 
undermined ; the floor is covered with an unhealthy, 
partly purulent slough, usually well attached, with 
dull-colored granulations springing from its mass. The 
color of the whole is characteristically empurpled and 
unhealthy. The prominent club-shaped aspect of the 
distal phalanx, swollen to two or three times its usual 
volume, presents a vivid contrast with the adjacent and 
unaffected phalanx, which seems in comparison to be 



SYPHILITIC AFFECTIONS OF THE NAIL. 1 39 

shrunken or atrophied. Viewed at a distance, the 
deformity often seems to be produced by a pushing 
of the nail-substance, whether involved or not, far to one 
side of the longitudinal axis of the digit, the reason for 
this being the bulk of the swollen and inflamed tissues 
on one side of the phalanx. The nail may be lost or 
partially destroyed in the process. The new-formed nail 
may be misshapen or well formed. As a rule, the repair 
procured by the best treatment is surprisingly good in 
view of the marked deformity and the threatening cha- 
racter of the lesions, especially when, as may be the case, 
many of the fingers are simultaneously attacked. 

This complication, usually occurring in the first two 
years after infection, is often a portent of grave syphilis ; 
it is apt to occur in middle-aged patients with broken- 
down constitutions. 

Chang-es in the Nail, with and without Involvement 
of the Adjacent Tissue (Onychia syphilitica). — (a) 
Atrophic Changes in the Nail. — Every grade of atrophy 
of the nail may occur in syphilis, and the milder forms 
are much more common than is generally supposed. 
They are often detected by the expert in his examina- 
tions when they escape the attention of the patient. In 
the simpler manifestations the nail-substance loses its 
lustre, acquires a dirty-yellowish hue, and slowly covers 
itself with various striations, markings, dots, and spots, 
often presenting a characteristic " worm-eaten " appear- 
ance. The friability of the nail is increased to a per- 
ceptible extent, and its broken or nicked free edge is seen 
in many, if not all, the digits, especially those of the 
fingers (onyxis craquele of the French). 

{p) Hypertrophic Changes in the Nail (Syphilitic on- 
ychauxis). — In this form, which may coexist with the 



140 SYPHILIS AND THE VENEREAL DISEASES. 

atrophic changes described above, and which is rarer 
than all others, portions only of the nail may be per- 
ceptibly thickened by increased growth, or the entire 
nail may be enormously increased in bulk, changed in 
color, and marked by the pinhead-sized dots or depres- 
sions, sharply cut in outline, where small circumscribed 
atrophic changes have occurred. 

(c) Separatio7i of the Nail from Matrix, Bed, or Fold. 
— This change, an exceedingly common one in syphilis, 
may involve one or all the nails of the hands and the 
feet. As a rule, several of the digits are affected, the 
hands by preference. The detachment may be partial 
or total. 

Among partial detachments, much more common than 
all others, the mildest is seen in early periods after infec- 
tion. The separation usually occurs first at the distal 
extremity of the nail where it is attached to the side of 
the nail-bed, and is visible beneath the nail-substance 
as a delicate linear or ribbon-like stripe, parallel with 
the long axis of the nail, resembling a serous exudation 
beneath the nail-substance ; or the line of separation is 
whitish in hue, and the separation occurs at the bottom 
of the nail-groove or across the entire width of the nail. 
One-half or more of the nail may thus be detached from 
its connections, the separated substance undergoing the 
usual changes in color and polish. 

When the separation is complete, it may result from 
changes beginning as in the partial forms described 
above, or with changes in the matrix, the latter being 
more common. Usually the latter ceases to provide for 
the further growth of the nail-substance, and the nail 
which is to be shed is simply slid along its nail-fold 
until it is exfoliated, undergoing meanwhile the atrophic 



SYPHILITIC AFFECTIONS OF THE NAIL. I4I 

changes already described, in markings, striations, etc. 
upon its surface. When the nail-bed is left bare it is 
speedily covered with a substance which, in all favor- 
able cases, eventually furnishes a new nail. 

Variations from this type are furnished by defective 
and imperfect attempts, instead of by total cessation of 
effort, of the matrix to furnish the nail-substance. In 
the former event ridges of mingled atrophic and hyper- 
trophic nail-substance mark the boundaries between the 
diseased plate, newly formed, and the healthier nail pro- 
duced prior to the date of the infective process. As a 
result the nail is shed, and its successor is formed after 
a lapse of time in which the nail-bed is in part exposed 
and beset by imperfectly formed, thinned, irregular, or 
" worm-eaten " fragments of horny substance. 

Diagnosis. — In general, the nature of the disorder of 
the nails is readily established, as there is usually a his- 
tory, and in almost every instance other symptoms, of 
infection. The indolent course of the disease, the tend- 
ency to ulceration of the soft parts about the nail, and 
the deformity resulting in the production of a bulbous 
or club-shaped distal phalanx, are all significant. In- 
growing toe-nail, chiefly of the large toe, presents an 
obvious explanation for the tumefaction and pain. 
Chancres seated in the site of a " hang-nail," especially 
among physicians infected in the practice of their pro- 
fession, are commonly associated with enlargement and 
induration of the epitrochlear gland of the limb involved. 
Tuberculous affections from inoculation of the manual 
digits are rarely situated at the nail-border, and they are 
usually of verrucous rather than of papular type. 



142 syphilis and the venereal diseases. 

Syphilis of the Mouth and the Tongue. 

The study of syphilis as it affects the mouth is of 
great importance because of the frequent implication of 
this cavity, because of the persistence and significance 
of the symptoms presented, and because of the possi- 
bilities of transmission of the disease amply afforded. 
In such a region as this is well illustrated the tendency 
of the disease to exhibit its symptoms at sites of special 
irritation. The chewing and smoking of tobacco, the 
holding of pipes, cigars, and cigar-holders in the mouth, 
and even the practice of chewing a toothpick after 
meals, are fruitful sources of lesions in this region 
of the body. The drinking of very hot or iced fluids 
and the use of highly- spiced, acetous, or salted foods 
have a similar tendency. 

Chancres occurring upon the tongue, the lips, and the 
tonsils have been considered elsewhere. It is needful 
here to recall the fact that lesions suggesting in appear- 
ance mucous patches of the tonsils, with an ashen sur- 
face and deep engorgement, deep indurations of the 
anterior segment of the tongue capped with a super- 
ficial abrasion or ulcer, and circumscribed scleroses with 
much tumefaction of the inside of the cheek or the 
gum, if associated with dense induration of the glands 
anatomically connected with these parts, should not 
hastily be taken for symptoms of consecutive syphilis. 

The lesions of systemic syphilis in the oral cavity are, 
when more or less speedily succeeding the appearance 
of the chancre, usually superficial, multiple, and well- 
nigh symmetrical, as distinguished from those occurring 
later in the disease, which are often single and deep as 
well as destructive. 



SYPHILIS OF THE MOUTH AND TONGUE. 1 43 

These lesions correspond strictly with those already 
studied as of occurrence in the skin, being of the type 
of macules, papules, tubercles, warts, scales, pustules, 
gummata, and ulcers. Each type, however, acknow- 
ledges a modification due to the peculiarities of site, 
the mouth being habitually moistened with mucus and 
saliva, and being exposed to friction of contiguous sur- 
faces and of articles of ingested food and drink, which, 
as already shown, add the effect of heat, cold, and 
chemical agents to the other effective causes of disease 
in this region. Again, the pressure upon the tongue 
and the inner face of the cheeks of carious and even 
sound teeth having projecting edges, not appreciated in 
conditions of health, is capable of inducing or modifying 
the symptoms here presented. As a rule, however, the 
syphilitic lesions of the mouth are of moist rather than 
of dry type, with the result that the mucous patch is 
probably of greater frequency as a syphilitic symptom 
than any other lesion exhibited in the course of the dis- 
ease, particularly in male patients using tobacco. 

Macular Syphilis of the Mouth. — Well-defined 
broad areas of vivid or dusky redness may often be seen 
over the arch of the soft palate, upon the tongue and 
the pillars of the fauces, and along the gingivo-labial 
furrows soon after general syphilis is declared. At 
times the redness is limited to finger-nail-sized plaques, 
or even punctate spots of heightened color, upon the 
mucous membrane. These spots may disappear on 
proper treatment, or they may persist and furnish a basis 
for the evolution of one or more of the other lesions to 
be mentioned. 

The chief complication of patches of this type is the 
assumption of an erosive and superficial or ulcerative 



144 SYPHILIS AND THE VENEREAL DISEASES. 

and deep action, due, as a rule, to the irritant effect of 
the agencies already described. In milder expression 
the epithelium loses its attachment to the underlying 
tissue in consequence of a macerative effect upon the 
weakened membrane, and the reddish pellicle first seen 
on examination disappears, leaving a raw-looking and 
tender spot the size of the original macule. In other 
cases a sharply-cut ulcer results, with floor more or less 
speedily extending to the depth of the mucosa, assuming 
a linear shape with its long axis at right angles to the 
lines of traction (along the width of the tongue, parallel 
with the groove of the gingivo-labial junction, etc.). 

The papular syphiloderm is represented on mucous 
surfaces by the mucous patch [plaque muqueuse, mucous 
tubercle, moist papule, etc.). These lesions are single or 
more commonly multiple, usually very well defined 
patches, which, being at first, and usually but for a 
brief time, reddened macules, speedily acquire an opaline 
hue over their flat surface, suggesting the action of 
nitrate of silver upon mucous membrane. They vary in 
size from a split pea to that of a bean, but they are often 
of greater size, involving a space as large as a penny or 
as extensive as the inner face of the lip or the arch of 
the palate. They are roundish, oval, or very irregular 
in contour, and they are often perceptibly raised above 
the general level. They are usually painful, and they 
are often seen en face on membranes in contact, such 
as the inner face of the cheek and the gum, and the two 
halves of the angular crevice behind the last molar 
teeth. A variation of this lesion is seen when a diph- 
theroid and bulkier film extends over the face of the 
patch or patches. 

The most common complication of this lesion is the 



SYPHILIS OF THE MOUTH AND TONGUE. 145 

superficial erosion which succeeds it, and which becomes 
visible as a vivid or dull-reddish, moist and shining or 
dry and glazed sequel of the removal, by friction or 
other agency, of the pellicle of epithelium covering the 
typically developed mucous patch. The elevation of 
these plaques by infiltration is not uncommon, and a 
further but rarer complication is furnished when this 
hypertrophic effect is exaggerated. In the latter event 
a well-elevated roundish disk, obviously thickened, and 
often with a distinctly elevated rim, rises, especially 
within the labial angles, but also elsewhere ; this disk is 
usually less painful than the simplest expression of the 
mucous patch, and is annoying chiefly by reason of its 
interference with the motions of the mouth. Often it is 
traversed by one or more fissures, which are then painful 
and apt to bleed when the tissue is unusually stretched. 

Papules of moist type — seen on mucous membranes, 
and much more rarely in the mouth than about the 
vulva or the anus — also at times assume a verrucous 
aspect, and are represented by growths resembling the 
pointed wart or the venereal wart, already described. 
They are usually smaller in the mouth than in the other 
regions where they occur, they do not furnish an offen- 
sive secretion, and they are more amenable to local 
treatment. The so-called " toad's-back " appearance of 
the tongue is produced by the confluence of a number 
of flattish and aggregated papules, each retaining its 
individual outlines, and producing thus an effect resem- 
bling the markings on the carapace of a terrapin. 

Ulcerative complications of the papules of syphilis in 

the mouth (mucous patches, etc.) are of the type already 

described, superficial and often exquisitely painful in the 

earlier and less irritative stages, deeper and reaching to 

10 



146 SYPHILIS AND THE VENEREAL DISEASES. 

the corium and beyond in the greatly irritative and later 
lesions of the disease. Ulcers here have a marked tend- 
ency to creep along the lines traced by the angles of 
adjacent surfaces, but they also occur as formidable 
circular lesions in the crypts of the tonsil, on the poste- 
rior wall of the pharynx, and on the inside of the lips. 

Tubercular lesions of mucous membranes are simply 
enlarged papules developing with complications of the 
types described above. Pustules occurring in the syph- 
ilitic mouth are results of secondary infection with staph- 
ylococci ; they are usually seen only after rupture of the 
roof of the lesion, when the floor of the original chamber 
is to be recognized as an erosive or ulcerative patch. 

The fissures which form as a result of syphilis of the 
mouth may be complications of one or several of the 
lesions described above, or may be the direct results of 
local irritation at certain special sites. These sites are 
the outer angles of the lips, often involving both the 
mucous and cutaneous surfaces, the margins and dorsum 
of the tongue, and the muco-cutaneous borders of the 
centre of the lips ; but they also develop elsewhere. 
Care is required to recognize even deep longitudinal fis- 
sures of the tongue, the walls of the crevices, when the 
organ is protruded, often falling together and wholly 
concealing a crack extending deeply beneath the mucous 
membrane. 

The squamous lesions of syphilis in the mouth are of 
the type usually described as " dry," the failure of secre- 
tion at the involved points being usually conspicuous. 
They appear, rather more rarely than mucous patches, 
on the borders of the tongue, on the inner aspect of the 
lips, on the lingual tonsil, and along the line of the 
inner faces of the cheeks corresponding with the junction 



SYPHILIS OF THE MOUTH AND TONGUE. 1 47 

of the teeth of the upper and lower jaws. They are 
dry, infiltrated, and usually circumscribed patches, 
rarely as uniformly rounded or oval in contour as 
mucous patches, and linear in shape or in ribbon-like 
bands. Their color is grayish or bluish-white, occasion- 
ally almost silver-white with a lustrous aspect. Often, 
when seated upon the tongue, the affected organ has a 
shaven appearance, the French from this circumstance 
giving to this condition the term glossite tonsurante^ 
Livid, opaline, bluish-white, slate-tinted, and otherwise 
colored patches of thickened and scaling epidermal tissue 
are often seen in the mouths of syphilitic patients, espe- 
cially of men who have been chewers, and more fre- 
quently smokers, of tobacco. These conditions may be 
observed in the first, second, or any subsequent year 
after the date of infection. They are at times amenable 
to treatment, but they are often refractory. 

Leucoplasia of the Mouth (Leucokeratosis linguae ; 
Leucoma buccae; Psoriasis linguae ; Leucoplakia buc- 
calis ; *' Smoker's patches of the mouth," etc.). — It is 
impossible to study the scaly patches of the mouth 
occurring in syphilis without considering a series of 
phenomena exhibited in this region, the pathological and 
clinical position of which, with respect to syphilitic and 
other disease, is not yet completely established. By 
no distinctive features can these symptoms be in each 
case assigned with certainty to one category or an- 
other. They stand in different cases in some relation 
to syphilis, to epithelioma, and to lichen planus. What 
is definitely known can be summarized as follows : In 
male patients, almost exclusively in smokers, but also 
in others, appear patches, striae, spots, plaques, fan- 
shaped lesions, and bands of a dull-whitish, opaline, 



148 SYPHILIS AND THE VENEREAL DISEASES. 

lead-white and silver-white tint, smooth and shining or 
roughened and beset with milium-sized nodules, which 
are consecutive to mucous patches or which occur in 
the mouths of syphilitic patients where such lesions 
have existed. They occur along the line of the jaws, 
on the gums, at the commissure of the maxillae, in the 
folds between the lips and the gums, on the sides and 
dorsum of the tongue, and elsewhere. They may be 
the seat of fissures or may result in ulceration. In 
rare cases they exfoliate ; still more rarely there may 
occur a highly exaggerated hypertrophy of the impli- 
cated tissue, in which a stripe of dead-white, thickened, 
and exceedingly dry tissue covers the dorsum of the 
tongue or one of the other regions named above, this 
tissue being so bulky as seriously to interfere with the 
necessary movements of the mouth. Epithelioma, not 
only in those of advanced years but in men of middle 
age, is liable to result from the long-continued irritation 
of the part. In other cases the disease is without ques- 
tion a lichen planus of the mouth, not to be distin- 
guished as to etiology from the other patches here 
described, seeing that lichen planus of the integument 
often responds to a very marked extent to the agents by 
which the involved tissue is irritated. 

It is practically impossible in many cases to draw a 
distinction, merely from the clinical appearance, between 
these several symptoms, nor is the fact greatly to be re- 
gretted. The leucoplasic condition is, in fact, not a disease, 
but a symptom common to several diseases. As pigment 
settles about the syphilitic and eczemato-varicose ulcer 
of the leg, and as the elephantiasic affection of the same 
organ occurs as a complication of syphilis, lymphangitis, 
erysipelas, and other maladies, so the scaling patches of 



SYPHILIS. 



Plate 




SYPHILIS OF THE MOUTH AND TONGUE. 1 49 

the tongue irritated by tobacco-smoke, carious teeth, 
neglect, and bad treatment form in both the syphiHtic 
and the non-syphihtic patient, in the victim of hchen 
planus and in the patient who eventually succumbs to a 
grave cancerous affection of the mouth. It is safe, in 
all cases admitting of any doubt, either carefully to ex- 
clude the possibility of syphilitic infection or to treat 
the patient for that disorder. 

Gummata of the Mouth. — Gummata occur in all the 
regions of the mouth as circumscribed or diffuse infiltra- 
tions, but they are most often encountered in the mass 
of the tongue, usually on one side, with well-defined 
limitations. They begin as insidiously evolved pin-head 
to small-egg-sized masses, usually single, at times mul- 
tiple, though rarely numerous, breaking down into 
ragged ulcers with a rapidity and a facility not noted 
in the course of similar lesions of the derma. They 
occur, as a rule, several years after infection, but in ob- 
tinate users of tobacco, especially in chewers (as dis- 
tinguished from smokers, who suffer from mucous and 
scaly patches), they have been seen as early as during 

^ the first year of infection. 

P When the hard palate is involved, it is common to 

discover in nearly the centre of the palatine vault a len- 
til-sized firm mass, which with astonishing rapidity 
softens until it exhibits a central orifice through which a 
probe can detect dead bone. In other cases a painless 

I or possibly slightly tender gummatous nodule of the hard 
palate may persist for months without softening, atten- 
tion being called to it by a persevering explorer of the 
case of a patient suffering from some other obscure symp- 
tom of the disease, upon which important light is shed 



150 SYPHILIS AND THE VENEREAL DISEASES. 

gummata form and rapidly disintegrate, the result in 
grave cases is only equalled by the severe ravages of 
cancer in the same region. The oral and nasal cavities 
are in these cases rapidly fused until they expose to view 
a single gaping chasm, with the possibility of perform- 
ance, imperfect yet surprisingly satisfactory, of neces- 
sary function. Here, as so often in the history of 
destructive syphilis, the repair wrought by skilful treat- 
ment is extraordinarily happy in results. The huge 
clefts and cavities of the tongue close, with the produc- 
tion of a sound scar-tissue which may resist disease for 
the remainder of life, and from which one can scarcely 
estimate the degree of the original damage. The use 
of an obturator, after all ulcers have been healed, by 
cutting off the nasal from the oral cavity may restore to 
the voice its natural timbre. All these grave changes 
occur in broken-down subjects of disease, or in those 
from some cause specially predisposed to complications 
of this character. 

Diag-nosis. — The distinction between scaly patches, 
lichen planus, and smoker's patches has already been 
considered. Cases are of frequent occurrence where a 
differential diagnosis is impossible, for the reason already 
given — that the conditions described under these terms 
are often symptoms common to several diseases. Mer- 
curial stomatitis with ulceration is readily distinguished 
by the fetor of the breath, the symmetrically swollen con- 
dition of the tongue, the indentation of its sides by the 
teeth, and the line at the border of the gums. The con- 
dition known as exfoliatio areata lingiicB (a phrase de- 
scribing symptoms rather than a disease) is characterized 
by the occurrence, especially in subjects of a tender 
age, though adults also suffer, of a well-defined elevated 



SYPHILIS OF THE MOUTH AND TONGUE. 15I 

patch spreading in circular outline over the tongue in 
areas as large as a penny and larger, leaving the tissue 
where it has extended smooth and varying in color, 
in different cases, from a light rosy shade to an em- 
purpled hue. Often the patch dips down over the tip 
or the sides of the tongue. The area is commonly uni- 
lateral in site, not often symmetrically involving the two 
sides of the organ. However much these areas may sug- 
gest syphilis, they are, as a matter of fact, rarely seen in 
that disease. In some cases they are, without question, 
the result of grinding the tongue between the teeth in 
the sleep of young patients with digestive disorders. 

Epithelioniatoiis changes in the mouth are often diffi- 
cult to distinguish from syphilis of the same region. In 
cancer the process is slower than in syphilis ; the patient, 
as a rule, is older ; the pain is commonly greater ; the 
floor of the resulting ulcer is more florid; the lesion in 
advanced cases is larger and bulkier ; in less advanced 
cases there is a decided tendency to assume a verrucous 
or fungiform aspect; the edges of the ulcerated patch 
are everted ; and the disturbance of function is decidedly 
greater. In any advanced case the degree of cachexia 
produced is practically the same in the two affections. 

In tubcrcitlosis of the mouth the lesions are slow of 
evolution, are usually at first superficial, and are not 
often limited to the tongue; the induration is slight; the 
ulceration is superficial and is studded with puncta of 
caseous degeneration; and systemic sympathy is marked. 
In all these diseases glandular enlargement may accom- 
pany the mouth-lesions, but in carcinoma the adenopathy 
of typical cases is more constant ; it is less frequently 
noted in tuberculosis ; and in syphilis it chiefly compli- 
cates chancre of this region. 



152 SYPHILIS AND THE VENEREAL DISEASES. 

Femphigus vegetans and other forms of pemphigus and 
herpes in many cases exhibit mouth-symptoms. The 
mucous membrane of the mouth is then usually raw, 
red macules representing the floors of bullae whose 
roof-wall has been ruptured. In these patients there 
are pain, exquisite sensitiveness of the mouth, and in bad 
cases extreme dysphagia ; but the presence of bullous 
lesions elsewhere, the temperature record of the patient, 
and the relative acuity of symptoms are all significant. 

Patholog-y. — Anatomical study of sections of tissues 
in most of the complications described above indicates 
that the inflammatory, hyperplastic, sclerous, gumma- 
tous, and degenerative processes in the mucous and sub- 
mucous tissues are in all respects analogous to those 
recognized in the skin and in the subcutaneous tissues. 
Small-celled infiltration, interstitial hyperplasia, epider- 
mal hypertrophy, elongation and thickening of the 
papillae of the corium, endarteritis, and increase in the 
number of rete-cells, often with smaller cells within the 
limits of the original protoplasmic envelope, are to be 
recognized in most processes. The presence of giant- 
cells in numbers, as well as of bacilli, distinguishes 
tuberculous disorders of the mouth; while nests of 
cells in the corium are characteristic of the epithelio- 
matous changes to be recognized as complications of 
leucoplasic patches. 

Syphilis of the Respiratory Tract. 

Syphilis of the Nasal Passages. — The frequency of 
involvement of the nose and the nasal passages in 
syphilis is due to the exposure of these regions in so 
many cases to climatic and other influences, as well as 
to the anatomical peculiarities of the parts. 



SYPHILIS OF THE RESPIRATORY TRACT. 1 53 

Chancres within the borders of the nares are exceed- 
ingly rare. An indurated lesion following, after a 
proper interval, the employment of instruments for the 
treatment or observation of any disorder of this region, 
if accompanied by enlargement and induration of the 
neighboring glands, should be regarded as highly suspi- 
cious. In the early periods of syphilis the more com- 
mon affections of the nose are acute and chronic rhin- 
itis, macular and mucous patches, and circumscribed 
and diffuse gummatous infiltration of tissue. In these 
cases the chief symptoms are local thickenings, a sero- 
purulent discharge from the nares, and sensations of 
pain and fulness of the part. Gummatous changes may 
occur in any portion of the nasal cavity, beginning with 
the mucous and submucous tissue, and spreading thence, 
often with destructive violence, to periosteum and bone. 
So delicate are the osseous and other structures of this 
region that their involvement may be followed by de- 
generative results in an incredibly brief time. A patient 
complaining of nasal symptoms may even in the course 
of a few days suffer a perforation of the septum or ex- 
hibit bony sequestra exfoliated and thrown off in a fetid 
discharge. At times the turbinated bodies enlarge and 
exhibit traces of fibroid degeneration. The term o:^cBiia 
was formerly given to the catarrhal s}'mptoms common 
to these patients, a disgusting odor being imparted to 
the breath by the destructive changes going on in peri- 
osteum and bone, accompanied by discharge of a puru- 
lent, hemorrhagic, or serous fluid often mingled with 
detritus of bone. The highly offensive odor of this 
secretion is often as disagreeable to the patient as to 
those with whom there is personal contact. As a result 
of the several changes indicated, the bridge of the nose 



154 SYPHILIS AND THE VENEREAL DISEASES. 

may be destroyed, producing thus a saddle-shaped flat- 
tening, with at times a tilting upward of its tip — a 
deformity as characteristic of syphilis as the " parrot's- 
beak " shape and the subsequent destruction of the tip 
are peculiar to lupus of the same organ. It is by 
these processes that the arch of the palate is perfo- 
rated and at times practically destroyed. Other sequelae 
of this disorder are the production of bridles and bands 
stretched from one side to another of the nasal cavity ; 
the obliteration of the passages by cicatricial occlusion ; 
and in grave cases, when severe osseous changes have 
taken place, the extension of the disease to the menin- 
ges of the brain with resulting convulsions and a fatal 
issue. 

Syphilis of the Pharynx. — Chancre of the tonsil has 
already been described, its erosion being commonly situ- 
ated on the inner face of the tonsillar mass, which is then 
enlarged, painful, and apt to be covered with an ashy- 
looking pultaceous slough, the glands beneath the jaw 
suggesting the nature of the difficulty. The opposite 
tonsil often sympathizes with the disorder, being en- 
gorged and at times eroded. 

The posterior wall of the pharynx is often the seat of 
circumscribed and diffuse inflammatory thickening (due 
to syphilis) and of mucous patches and gummata. There 
is in these cases a very characteristic smearing of the 
fauces with a tenacious mucus, frequent efforts being 
made by the patient in hawking to rid himself of the 
resulting discomfort. Fibroid thickening and gumma- 
tous ulceration are not rarely encountered, a character- 
istic ulcer resulting from these changes being recognized 
as a circular, well-defined excavation, with clean-cut 
edges and sloughy floor, visible chiefly on depression 



SYPHILIS OF THE RESPIRATORY TRACT. 155 

of the base of the tongue. Grave destructive results 
in extreme cases extend to the bone and to the large 
vessels lying near the pharynx on either side. Vegeta- 
tions and verrucous growths are rare in this region. 

Syphilis of the Larynx. — The morbid changes in 
the larynx due to syphilis occur in early and late periods 
of the disease, and in both circumscribed and diffuse 
manifestations. These changes may result from others 
occurring in the upper portion of the respiratory tract 
(nares and pharynx), or they may develop primarily in 
the larynx itself 

Macular lesions with transient or persistent erythema 
are not rarely encountered on the mucous surface ; as a 
result, the submucous tissues may be involved in deep- 
seated infiltration. The complications are erosions and 
superficial ulcers seated on an engorged base, or more 
rarely on a surface not changed in hue from the normal, 
visible, on laryngoscopic examination, over the epiglottis, 
the vocal cords, the ventricular bands, and other parts. 
Symmetrical, multiple, shallow ulcerations, involving 
with relative acuity several portions of the larynx at one 
time, are peculiar to syphilis. In some cases the plane 
macular surface changes to one that is decidedly elevated, 
exhibiting a grayish and reddish tint suggestive of 
mucous patches in the mouth, though it is to be observed 
that typically developed mucous patches are rarely seen 
in the larynx, on account of its relative protection from 
many of the effective causes of these lesions in the mouth 
and the nose. 

Later, deeper and more serious accidents to the lar- 
ynx result from gummatous changes. The deposit is in 
the form of single or multiple, milium-sized nodules or 
diffuse infiltrations involving the submucous tissues of 



156 SYPHILIS AND THE VENEREAL DISEASES. 

either the epiglottis, the interarytenoid space, the vocal 
cords (particularly their free border), or the subglottic 
folds, these growths being sufficient in extreme cases 
seriously to interfere with the functions of the larynx. 
The mucous envelope of the gummata may at first be 
intensely hypersemic and even covered with a vascular- 
ized membrane of a vivid red color, or the hue may be 
yellowish, grayish, or even scarcely altered from that of 
the surrounding part. The result may be complete in- 
volution without further change — an occurrence by no 
means rare in healthy subjects under proper treatment; 
or, exceptionally, ulceration may ensue, and that to a 
degree of gravity inducing partial destruction of peri- 
chondrium, cartilage, or bone. At times fibroid tumors 
resembling gummata in external form spring from irri- 
tated patches where macular lesions or erosions have 
existed, inducing as much suffering and exposing the 
patient to as much danger as other new growths of this 
region. Again, membranoid bridges, bridles, and bands 
stretch from one side to another of the laryngeal cavity, 
occluding its lumen and producing subjective symptoms 
not differing from those resulting from the presence of 
tumors. Verrucous growths also develop about the ven- 
tricular folds, proving formidable by their interference 
with the movements of the organ. There may result 
from any of these changes characteristic ulcers, single or 
multiple, usually the latter in late syphilis, with defined 
elevated and hyperaemic margins, often surrounded by a 
zone of inflammation, covered with a pultaceous slough. 
These ulcers when healed leave cicatrices which, as they 
contract, may either prove harmless or may draw together 
the walls or folds of the larynx, or fasten the epiglottis 
to the tongue or to the pharyngeal wall. Suppuration 



SYPHILIS OF THE RESPIRATORY TRACT 1 5/ 

of one or more recesses of the organ, deep-seated abscess, 
ankylosis, paralysis, hemorrhage, sudden and dangerous 
oedema, and the presence of a necrotic cartilage in the 
larynx acting as a foreign body, are all complications of 
severe types of the disease. 

The chief symptoms recognized without laryngo- 
scopic examination of the patient are a characteristically 
hoarse and raucous voice, cough, dyspnoea, and cephalic 
symptoms due to imperfect aeration of the blood. These 
symptoms vary from the mildest to the severest distress, 
the dyspnoea in extreme cases requiring tracheotomy. 
A middle-aged man with a voice reduced to a faint 
whisper, full inflation of the lungs being effected by 
deep inspirations at long intervals, should invariably be 
studied with a view at least, before all else, to setting 
aside the diagnosis of syphilis. 

It is to be noted carefully that while experts in laryn- 
goscopy often find in doubtful cases of this category 
products of simple inflammmation, and even foreign par- 
ticles, choking the chink of the larynx, the onset of 
these troubles is generally to be ascribed to localized 
syphilitic manifestations interfering with the normal 
action of the glottis. As it is the syphilitic mouth which 
early and late acknowledges the unfavorable influence 
of tobacco, so the syphilitic larnyx is exposed to irrita- 
tion by the unfavorable influences of dust, smoke, and 
an insalubrious atmosphere. 

Diagnosis. — In tuberculosis of the larynx the existence 
of pulmonary symptoms of disease, the general physical 
aspect, condition, family history, and age of the patient, 
and the discovery of bacilli in the sputa, usually suffice 
to determine the nature of the disorder. With respect 
to age, it is interesting to note that tuberculosis of the 



158 SYPHILIS AND THE VENEREAL DISEASES. 

larynx generally occurs at an earlier period of life than 
does syphilis of that organ with grave complications. In 
tuberculosis, as a rule, the affected membrane is lighter 
in color, the process is slower, the ulceration is more 
shallow, the damage in extreme cases is far less serious, 
the dysphagia and the constitutional effect are far more 
pronounced, and the fatal issue is more probable and 
imminent than is the case in syphilis. On the whole, it 
may be said that a striking feature of syphilis of the 
larynx is that recognized in syphilitic involvement of 
many other organs — namely, a singular toleration on 
the part of the patient of even a serious mutilation or 
destruction. 

Carcinomatous, as distinguished from syphilitic, in- 
volvement of the larynx is a disease of later life, develops 
in much slower course, and is often accompanied by 
hemorrhage, which is relatively rare in syphilis. 

Tlie prognosis in the great majority of cases is favor- 
able. After wellnigh complete aphonia for months and 
even for years, restoration of the voice has been secured. 

Syphilis of the Trachea and the Bronchi. — Lesions 
of the trachea and the bronchi due to syphilis are far 
rarer than those of the upper air-passages, or, if occurring 
more frequently than is believed, they for the most part 
escape observation. In general, it may be said of syph- 
ilis of the air-passages that its invasions are from with- 
out inward, and in the matter of frequency and multi- 
plicity are conspicuous the shorter the excursion from 
the lips and the nares. The more deeply, however, syph- 
ilitic lesions spread toward the bronchi and the lungs, 
the greater, as a rule, is the gravity. 

The changes noted in the trachea and the bronchi are 
practically those studied in the larynx, with differences 



SYPHILIS OF THE BONES. 1 59 

due to the changed anatomical situation. The lesions 
may be consecutive to those occurring in the larynx, or 
they may be developed d'emblee. Circumscribed and 
diffuse patches of inflammation, fibroid changes, gum- 
mata, erosions, and ulcerations are the chief lesions in 
the course of which the perichondrium and cartilages 
may be involved, Membranoid occlusion of the trachea 
and of one bronchus, extreme stenosis, cicatricial stric- 
ture produced by bridles and bands, and fistulous sinuses 
connected with abscesses of one or another region, 
usually the lower, are sequels of different cases. The 
entire trachea has been converted into a contracted and 
distorted tube as a result of a slowly spreading ser- 
piginous ulcer. 

Syphilis of the Bones. 

Periosteum and bone may be involved in both early and 
late syphilis, these complications occurring from a few 
months to a score or more of years after infection. The 
bones most frequently involved are those of the skull 
and the face, the palate, the tibia, the sternum, the clav- 
icle, the ribs, and the scapula. One or several bones 
may be simultaneously or successively affected ; rarely 
there is symmetrical involvement, as when both tibiae 
or radii are coincidently attacked. 

Most of the changes in these organs are due to cir- 
cumscribed or diffuse gummatous deposits either in the 
periosteum, between it and the osseous tissue, within the 
bone-substance, or in the medulla. These gummatous 
deposits by pressure upon contiguous structures may 
seriously impair the function of other important organs, 
as when the deposits spring from the inner tables of the 
skull. 



l6o SYPHILIS AND THE VENEREAL DISEASES. 

Gummata of periosteum and bone are circumscribed, 
commonly multiple, grayish or yellowish-gray nodular 
masses, occasionally in diffused patches. The perios- 
teum is usually first attacked. In regions accessible 
to the touch, as over the anterior face of the tibia, a 
well-defined swelling may then be recognized, covered 
with normal integument displaying symmetrical tume- 
faction, though at times beset with irregular and jagged 
projections. These tumors vary in size from a bean 
to that of a large ^gz\ they are usually tender and 
exceedingly painful even when not impressed with the 
contact of a foreign body, the pain being character- 
istically heightened at night by the warmth engen- 
dered beneath the bed-clothing. The nocturnal pains 
of periostitis and osteo-periostitis are, indeed, so uni- 
formly aggravated at night that they are generally 
considered diagnostic, and they are justly regarded 
with special suspicion in any case where syphilis had 
not been before suggested if they occur with quotidian 
regularity. They vary in character, being either boring, 
hammering, splitting, or crushing. When intense and 
characteristic, the patient is, as a rule, wholly unable 
to remain at rest, though he may secure transient relief 
by constant motion of the affected part, as when the legs 
are drawn upward and downward in bed — a series of 
movements highly suggestive of bone-syphilis. The 
pains are in part, without question, due to compression 
of inflammatory and other products between the tense 
and inelastic periosteum and the unyielding mass of the 
osseous tissue. These symptoms may in some cases be 
of purely inflammatory type, but, however acute, it is 
probable that in all cases the gummatous process is 
chiefly responsible for the result. 



SYPHILIS OF THE BONES. l6l 

When the bony tissue actually participates in this dis- 
order, the result is a node — a firm and more or less sen- 
sitive tumor, usually smooth and fairly well defined in 
outline, either globoid or exhibiting a longitudinal eleva- 
tion like the " splint" of a horse, its length parallel with 
the long axis of the limb. The pains are usually of the 
sort experienced in periostitis. The course of the node 
may be either complete involution, which usually occurs 
under treatment, or persistence as a less painful and ten- 
der, even wholly insensitive, bony growth, or degenera- 
tion by softening, the tumor breaking at the centre and 
leaving a typical syphilitic tertiary ulcer with exposed 
bone at the base, eventually healing after exfoliation of 
the sequestrum, with scar-tissue implicating both bone 
and integument. 

The resulting deformity depends upon the region 
involved ; that occurring after destruction of the bones 
of the nose has been described in the pages devoted to 
syphilis of that organ. The deformity resulting when 
the extremities, the skull, and the spine are attacked is 
far less significant in acquired than in inherited disease. 

Pathology. — Minute gummata of periosteum and bone 
are small-celled new growths tending to central degene- 
ration by breaking up of their molecular elements in a 
characteristic atrophy. The cells of the outlying por- 
tions are larger, and often are in communication with 
a new growth of fine vessels. The medullary sub- 
stance of the bone is at first increased in thickness. 
The term rarefying osteitis has been given to that 
process in which, while the marrow enlarges and the 
enlarging Haversian canals are stuffed with new cells, 
there is thinning and eventual absorption of the osse- 
ous trabeculae, forming thus spaces in which the gum- 
11 



1 62 SYPHILIS AND THE VENEREAL DISEASES. 

matous deposit is made, with the effect of producing a 
weakening of the actual osseous structure. Either the 
length or the thickness of a bone may be thus to gross 
. appearances greatly increased, while its substance is 
actually reduced. 

The term formative osteitis is given to that condition 
in which new bone is formed during the metamorphic 
changes described above, by the production of trabeculas 
originating in the embryonal cells in the medullary spaces, 
these cells commingled with corpuscles from the orig- 
inally involved bony tissue. The new growths may 
develop between periosteum and bone or from the sur- 
face of bone denuded of its covering. In this way the 
cavities produced may be filled with new bony tissue. 
In a more advanced stage the new osseous formation 
may undergo a sclerotic hardening, the induration be- 
coming as dense as ivory. Condensing osteitis, or ebiir- 
7tation, produces a new growth which encroaches upon 
the medullary cavity or, pushing externally, may pro- 
duce an annular, node-like, or splint-like appendage to 
the bone involved. These processes of rarefaction, bone- 
formation, and even bone-degeneration to the point of 
production of a sequestrum through an ulcerative open- 
ing, may occur simultaneously in different parts of one 
bone or side by side, one lamella thickening while that 
adjacent softens. This multiformity of processes is a 
characteristic feature of bone-syphilis. 

When the gummatous process involves the medulla, 
an osteo-myelitis may result, with degeneration and the 
bursting of an abscess externally, which is rare ; or a 
formative osteitis with encroachment on the lumen of 
the medulla, the latter condition being the more com- 
mon sequel. 



SYPHILIS OF THE BONES. 1 63 

Diag-nosis. — Bone-syphilis in acquired disease is 
usually recognized without difficulty, since the history 
of the patient and the character of the pains produced 
are suggestive. It is to be noted, however, that tempo- 
rary swellings along the axes of the tibiae occur in ery- 
thema nodosum, in which event there is usually, with 
tenderness of the node-like masses, marked redness of 
the integument covering the swelling. The acuity of 
symptoms is also suggestively different from the slow- 
ness of career of both syphilitic, tuberculous, and rheu- 
matic nodes of the same part. 

Secondary infection may occur in both periostitis and 
osteitis, and in such instances purulent foci result com- 
monly in abscess. In examination of bones with a view 
to determination of probable cause of death, the exist- 
ence of " worm-eaten " cavities, of irregular thickenings, 
and of perforations of entire plates of bone is indicative 
of syphilis. 

Syphilitic Dactylitis (Syphilitic panaris ; " Syphilitic 
finger"). — This affection, first described in a classical 
essay by Dr. Taylor of New York, requires special 
description on account of its characteristic features. 

This disorder is one involving the articular and peri- 
articular tissues of the digits, more particularly of the 
fingers ; it occurs in both inherited and acquired dis- 
ease. In a first variety the subcutaneous, fibrous, and 
connective tissues concerned in the formation of the joint 
are primarily involved, one or more phalanges exhibit- 
ing changes, chiefly on the dorsal aspect, slowly or (more 
rarely) rapidly, and with remissions or continuously. 
The process is essentially a gummatous infiltration of 
the structures concerned in the articulation. The digit 
is either over-flexed or over-extended, swollen, and cov- 



164 SYPHILIS AND THE VENEREAL DISEASES. 

ered with an empurpled integument; its motions are 
impaired ; and distinct crepitus is perceptible on palpa- 
tion, due to erosion of the cartilages composing the 
joint. Ankylosis, abscess, destruction of the capsule 
and the entire joint, or simple impairment of the function 
of the articulation, with repair, may ensue. 

In a second form the process is first instituted in the 
osseous, periosteal, or medullary structures, which 
become the seat of gummatous changes resulting in 
thickening of the two involved parts. The process 
may result, as shown above, in either rarefying, forma- 
tive, or eburnating osteitis, so that the digit may be 
increased or decreased in size, or become softish and 
cheesy when handled, or as firm as ivory. Ulceration 
and abscess bursting through the stretched and empur- 
pled skin may lead to the formation of fistulous tracts 
communicating with bone that is either carious or in 
process of slow repair. An oval, symmetrical tumor 
limited to a single phalanx of one or more digital or 
metacarpal bones, crepitating under firm pressure and 
painful and tender, is wellnigh characteristic of syphilis. 
The atrophy of a proximal or middle phalanx as a result 
of the processes here described, whereby a distal is made 
to fall upon a proximal phalanx, or the distal and middle 
phalanges upon the adjacent metacarpal bone, is highly 
suggestive of the same specific process. 

Care should be had to recognize the distinction 
between these deformities and those due to tubercu- 
losis, paronychia, and gouty or rheumatic affections of 
the digits. Lepra, the " melanotic whitlow " of Hutch- 
inson, and the lesions of syringomyelia are all to be dif- 
ferentiated. 



syphilis of the larger joints. 1 65 

Syphilis op the Larger Joints. 

Pains in the joints as well as in the bones and the 
muscles are not rare in early syphilis. These sensations 
do not necessarily imply the existence of a localized 
lesion of these organs, but they often point to neuralgic 
conditions due to the circulation of intoxicated blood. 
At times, without doubt, they are due to the action of 
mercury administered for the relief of that intoxication 
in persons peculiarly subject to the action of the metal. 

Synovitis and arthritis in syphilis may involve one 
or several of the larger joints simultaneously, in which 
case the symptoms /^r .?£ are scarcely to be differenti- 
ated from the same symptoms in the subjects of other 
diseases. The articulations are tumid, tender, painful, 
and hot to the touch, with limitations in flexion and ex- 
tension, and evident fluctuation when synovium is effused 
in a fluid form. Patients thus affected may exhibit 
pyrexic symptoms ; rarely have they been in good 
health prior to the date of syphilitic infection. As a rule, 
when examined they are pallid and weak. The termi- 
nation of the arthritic complication maybe by resolution 
without sequelae, by ankylosis, or by destruction of im- 
portant structures in and about the articulation affected. 

Pathology. — The synovial membrane is usually in 
these cases the seat of gummatous infiltration, with well- 
marked tufts springing from its surface ; or the sub- 
synovial structures, the ligaments, the capsule of the 
joint, the cartilage, and the subchondroid tissue may be 
involved, with the result of producing eventually thick- 
ening, degeneration, or the bursting of an abscess exter- 
nally, and the formation of sinuses connecting with the 
joint-cavity. 



1 66 SYPHILIS AND THE VENEREAL DISEASES. 

The diagnosis of syphilitic arthritis is made chiefly 
by consideration of other symptoms of the disease usually 
present, as well as by the history of the patient. Stru- 
mous, tuberculous, and other systemic affections exhib- 
iting arthritic symptoms may in general be recognized 
by the earlier age of the patient. In syphilis the knee 
and the sterno-clavicular and scapulo-clavicular joints 
are chiefly involved. The hip is very rarely attacked 
in syphilis. Adult male patients are liable to display 
these symptoms usually from two to four years after 
infection. 

Syphilis of the Burs^. 

The bursae may be acutely inflamed, with symptoms 
of tumefaction, tenderness, pain, sensations of heat, and 
redness or an unchanged color of the skin over the 
part ; but this complication is rare. More often an in- 
sidiously deposited gummatous material accumulates 
within or about the bursa. In practice the distinction 
is often well made between a gummatous degeneration 
of the tissue about a large bursa, later involving and 
opening into the latter, and a specific primary involve- 
ment of the sac. The subsequent career of the lesion, 
whether after resolution or after degeneration, is practi- 
cally that of the same process in the skin. When the 
prepatellar bursa or that over the tuberosity of the tibia 
is implicated, the disorder has been termed " tertiary 
syphilitic housemaid's knee." 

Syphilis of the Tendons and the Tendinous 
Sheaths. 

The tendons and the tendinous sheaths maybe acutely 
or slowly involved in gummatous processes beginning 



SYPHILIS OF THE MUSCLES. 1 67 

either in the teno-synovial sheath or in any of the con- 
tiguous parts. The process is usually accompanied by 
pain, swelling-, and disturbance of function. The issue, 
even after extensive hydrops, is usually complete resolu- 
tion, but more or less persistent thickening, ulceration, 
or agglutination of the tendon to its sheath may follow. 

Syphilis of the Aponeuroses. 

The aponeuroses may be involved in the processes 
of syphilis, usually by extension of gummatous infiltra- 
tions from adjacent tissues. The significance of this 
lies chiefly in the consequences to the structures with 
which such aponeuroses are in anatomical connection. 

Syphilis of the Muscles. 

Myositis occurs in syphilitic subjects in differing 
forms. It has been supposed that the muscular pains 
experienced soon after infection in any subject proceed 
from an " irritative myositis," but, as has been shown, it 
is probable that these pains are due either to the nerves 
supplying the muscles, which acknowledge the presence 
of a special toxine without change in the tissues, or to the 
special sensitiveness of some patients to the early action 
of mercury administered with a view to the relief of the 
disease. In any event, the muscle-lesions in such cases 
are not yet demonstrated. 

In chronic interstitial forms of myositis it has been 
demonstrated with sufficient clearness that a gummatous 
infiltration, diffused or in distinct foci, may involve the 
muscle-bundles, resulting in compression of the latter, 
with consequent pain, distortion, and even permanent 
contracture. The ultimate issue as regards the infiltrate 
is either fatty degeneration and coagulation-necrosis, 



1 68 SYPHILIS AND THE VENEREAL DISEASES. 

ulceration and fistulous connection with the outer in- 
tegument, or complete resolution with restoration of 
function. 

Progressive ossifying' myositis is a rare complication 
of formative and eburnating osteitis, though it is claimed 
to have resulted from changes in the central nervous 
system. 

Atrophy of muscles in syphilitic subjects, especially in 
those who have been its victims for years, is more com- 
mon than is usually believed to be the case. It may re- 
sult from (a) gummatous involvement of the nerves, the 
ganglia, or the tissues about the same ; (6) from gumma- 
tous deposits in the muscles themselves ; or {c) from dis- 
use of the limbs and the body in syphilitic subjects as a 
result of disease of other organs involving long-con- 
tinued decubitus, or of life in a wheeled chair (grave 
ulceration of feet and legs, severe ulceration opening 
into the knee-joint, etc.). 

Syphilis op the Heart. 

Pericarditis is a rare complication of syphilis ; it 
results from gummatous deposits in the fibrous tissue 
or from implication of the pericardia by the extension 
thither of a degenerative process originating in neigh- 
boring organs. 

Gummata in the form of distinct yellowish circum- 
scribed nodules may be found post-mortem in the septa 
and the substance of the heart, usually accompanied 
by hypertrophy and thrombus. On section these gum- 
mata are seen to be non-vascular and composed of a 
capsule of connective tissue within which lies centrally a 
sclerotic mass. In the tissue where these gummata have 
been implanted the muscles are replaced by fibrous bands. 



SYPHILIS OF THE HEART AND BLOOD-VESSELS. 1 69 

The fibrous myocarditis of syphilis is due, according 
to Councihnan, to an encroaching endocarditis affecting 
the coronary arteries, as a consequence of which the 
heart-muscles undergo various degenerations. Thesub- 
endothelial tissue of the heart may be responsible for 
changes which have been described as a syphilitic endo- 
carditis, in which whitish nodules have been detected 
along the free edges of the valves, with thickening 
and induration of the pericardium, shortening of the 
chords, and thrombi of the free surface. 

Aneurysm of the Heart. — In a few instances saccular 
dilatations of the ventricular space, with walls indurated 
in part and in part thinned, have been recognized post- 
mortem in the ventricles, one or several of such dilata- 
tions being visible in a single subject. 

Among all the lesions recognized after death in the 
heart and the vessels of the subjects of undoubted syph- 
ilis, it is difficult to determine which should be de- 
scribed as directly due to that disease, and which to 
the indirect results of cachexia and to the presence 
of a chemical toxine engendered by the mutual play of 
micro-organism and invaded tissue. Without question, 
some of the conditions described above are the indirect 
results of specific infection, the direct attack of which 
has been pursued along different lines. 

The symptoms of many of the lesions suggested 
above are not readily differentiated from those occur- 
ring in non-syphilitic subjects. They are fcr the most 
part betrayed in disturbances of respiration, prsecordial 
distress, angina, asthma, palpitation of the heart, and 
other symptoms accompanied by nocturnal aggravation. 
In the simpler syphilitic affections of the heart the dis- 
tress is usually paroxysmal, and the general condition 



170 SYPHILIS Ah'D THE VENEREAL DISEASES. 

of the patient is one of weakness occurring simulta- 
neously with the cardiac disturbance. Complete relief 
may ensue under treatment, but fatal results are re- 
corded in a proportion of recorded cases. 

Syphilis of the Blood-vessels. 

Arterio -sclerosis. — There are two forms of disease to 
which the title arteriosclerosis has been given. These 
are the diffuse and the circumscribed (or nodular) 
forms. Both are due to a primary fatty metamor- 
phosis of the muscular walls, with consequent dilata- 
tion of the lumen and compensatory increase of the 
intima of the vessel, which, as also the muscular over- 
growth, may subsequently undergo hyaline or atherom- 
atous degeneration. From these changes aneurysmal 
pouches may form ; and the modern view that all aneur- 
ysms not originating in trauma should be suspected to 
be syphilitic, is in part due to the fact that iodide of 
potassium has proved of value in so many instances. 

Endarteritis Obliterans. — In this special affection 
there is proliferation on the part of the endothelium 
of- the vessel, resulting in a thickening which eventually 
involves all the tunics of the vessel, and in an encroach- 
ment upon its calibre tending to obliteration. The pro- 
cess is differentiated from the arterio-sclerosis described 
above chiefly in the production of a neoplastic as dis- 
tinguished from the purely hypertrophic thickening of 
arterio-sclerosis. A gummatous periarteritis in which 
the adventitia and the media are involved has also been 
observed in both the circumscribed and diffuse forms. 
The hyaline and amyloid degenerations of the small- 
sized arteries, as well as the primary changes described 
above, are encountered as well in non-syphilitic disease. 



SYPHILIS OF THE LUNGS. I7I 

Here, as in syphilis of the skin, the mode of involve- 
ment rather than the lesion is characteristic of syphilis. 
It is the recognition of several necrotic points with re- 
striction of the lumen of the vessel by thickening of the 
intima that suggests the nature of the process in any 
given case. 

Syphilis of the Lungs. 

The great difficulty in discriminating between gum- 
mata of the lung and tubercles of the same organ has 
up to the present obscured the characteristic features 
of syphilitic disease. Gummata occur as firm, often 
quite dense, whitish, grayish, or reddish-gray nodules, 
set in consolidated lung-tissue, and varying in size from 
a split-pea to that of a small &%^. They are built up of 
granulation-tissue ; they degenerate rapidly by caseation, 
fatty metamorphosis, and central necrosis. Fibrous tra- 
beculae pass from the outer envelope of the mass toward 
its centre, as if to produce lobulation. These lesions 
are found in the posterior and lower lobes of the lung 
oftener than in its apices, furnishing thus a valuable 
diagnostic difference between syphilis of the lung and 
the apical disorders of early pulmonary tuberculosis 
[Spitzenkatarrli). Diffuse infiltration of gummatous ma- 
terial in the lungs is characterized by the consolidation 
of a smaller or larger area, as the result of accumula- 
tion in the alveoli of an epithelio-fibrinous exudate, or 
from a new growth of connective tissue. On section 
the lung closely resembles the condition seen in simple 
pneumonia, its substance being firm and in color grayish 
and reddish. Under the microscope the connective tis- 
sue is seen to extend from the blood-vessels into the 
thickened alveolar parietes, almost obliterating the alve- 



172 SYPHILIS AND THE VENEREAL DISEASES. 

oli or changing them into narrow clefts with epithehal 
Hnings. The absence of leucocytes is conspicuous. 
Councilman, who amply illustrated this subject, describes 
this condition as a " true syphilitic pneumonia." 

Qumraatous Fibrosis of the Lung-. — In this condi- 
tion the tissue about the bronchi and the arteries under- 
goes a fibrinous metamorphosis to the point of produc- 
tion of thick, cord-like radiations spreading from the 
root of the lung toward the pleura, inducing later, by 
contracture, both emphysematous and atrophic states 
of the constricted pulmonary tissue. Along these 
fibrous bands are set gummata of usual type which may 
degenerate by ulceration. Irregularly alternating points 
of constriction and dilatation of the bronchi produce the 
symptoms of bronchitis of non-specific type — evolution 
of pus-cells with thickening and erosions of the mucous 
surface. 

Ulceration in the lungs, with the consecutive forma- 
tion of cavities, as in pulmonary tuberculosis, has been 
both affirmed and denied as of occurrence in syphilis. 
There is good reason, however, to believe trustworthy 
the recorded cases in which cavities have been found, 
communicating or not with bronchi, surrounded by firm 
cicatricial tissue, and associated with other symptoms of 
that disease in unquestioned subjects of syphilis. 

Diagnosis. — The discovery of tubercle bacilli in any 
case is of the greatest value in establishing a distinction 
between syphilis and tuberculosis of the lungs. The 
physical signs of consolidation, dyspnoea, and cough are 
in the two usually similar. We have seen severe hemor- 
rhage, even to the point of fainting, with perfect re- 
covery. The chief important points are the localization 
of the disease in syphilis (as already shown) ; an ap- 



SYPHILIS OF THE G ASTRO-INTESTINAL TRACT. 1 73 

parent limitation of all symptoms, in certain cases, to 
the chest ; the remarkably good thoracic development 
and general physique of the subjects of the disease; the 
frequent absence of fever; and the marked dyspnoea of 
some of the affected. 

Syphilis of the Gastro-intestinal Tract. 

Syphilitic lesions of the oesophagus are known only 
in the report of a few isolated cases, upon which some 
doubt rests in consequence of their great rarity. Of 
cases in which the stomach is reported to have been 
involved, though the recorded instances are somewhat 
more numerous than of oesophageal invasion, but little 
is known of any characteristic symptoms. Gummatous 
infiltration of the mucous and submucous tissue is 
supposed to be responsible for areas of definite out- 
hne where at one or more points thickening and sub- 
sequent ulceration have occurred. Syphilis of the in- 
testinal canal is rarely encountered save in the ano- 
rectal pouch. Its lesions are due to gummatous deposits, 
either diffuse or in localized points, the latter often cor- 
responding with the sites of the agminate glands. The 
results are seen in fibrous thickenings and dense infil- 
trations, with ulceration at one or several points. Often 
there is coincident peritoneal adhesion and serous effu- 
sion. 

Syphilis of the Liver. — Gummata are not rarely found 
in the liver of the subjects of syphilis, where they appear 
as few or numerous grayish-red and grayish-yellow 
nodules lying near the capsule or deeply set in the sub- 
stance of the organ. When lying near the superficies 
they usually induce contracture of the hepatic capsule, 
which is also often thickened and attached to the 



1/4 SYPHILIS AND THE VENEREAL DISEASES. 

adjacent organs. The nodules are composed of con- 
nective tissue, which undergoes a metamorphosis into 
dense cicatricial bands appearing, when they are fully 
developed, to divide the hepatic mass into lobules. 
Centrally the nodules undergo softening and necrosis, 
due to obliteration of the vessels which supply them. 
Most observers agree with Virchow, that there is also a 
fibrosis affecting the syphilitic liver, not due to gum- 
matous deposits. In these cases fibrous bands stretch 
from the capsule in many directions, compressing the 
hepatic substance between the divisions thus artificially 
produced; which are further intersected by lesser stria- 
tions of fibres passing from the larger bands. The effect 
is very like the shrunken condition of the gland occur- 
ring in cirrhosis. As a sequence of this and also of the 
other changes noted above, amyloid degeneration both 
of the walls of the hepatic vessels and of the liver-cells 
themselves may occur. Calcareous metamorphosis is 
rarely seen, and ulceration is of rare occurrence. We 
have noted a single case only in which an adult within 
the first year of infection died apparently as the sole 
consequence of syphilis of the liver. This organ was 
stuffed with gummata to an extent interfering seriously 
with the performance of its function. 

During life it is rare that any symptoms are displayed 
sufficiently distinct to point unmistakably to hepatic in- 
volvement. Icterus is by no means rare in syphilis, 
especially in its early months ; there can be little ques- 
tion, however, but that the symptoms may be wholly due 
to functional derangement of the liver. Pain and tender- 
ness in the hepatic region, and ascites, may or may not 
be present. There are no signs absolutely diagnostic of 
hepatic disease in syphilis. 



SYPHILIS OF THE RECTUM AND THE ANUS. 1/5 

Syphilis of the spleen and of the pancreas is ex- 
ceedingly rare. When unmistakably involved, the spleen 
may be large and soft, as in non-syphilitic affections, 
or enlarged and indurated from fibrosis, or affected 
with diffuse, yet more rarely circumscribed, gummatous 
deposit. As usual in splenic enlargements, when volu- 
minous as a consequence of syphilis, the organ is usu- 
ally many times its normal size. 

When the pancreas is attacked, the lesions of syphilis 
are usually found in and about the head of the gland, 
which, like the spleen, may be either enlarged or dense 
and contracted. In the latter event the acini are firmly 
compressed, as in the case of the hepatic cells of the 
liver, by an interstitial overgrowth, corresponding with 
the condition of fibrosis found in the spleen. Circum- 
scribed gummata of this gland are rare, but they have 
been noted in both large and miliary-sized nodules. 

Gummatous changes of the suprarenal glands have 
been reported in a few instances. The affection may be 
said, however, in consequence of its great rarity, to be a 
pathological curiosity. 

Syphilis op the Rectum and the Anus. 
Chancres of the anal region are apt to be ignored in 
consequence of the fact that physician and patient do 
not usually suspect the nature of the trouble. In our 
experience these lesions, as distinguished from the soft 
chancres of the anal region occurring in women, are 
more common in men, and result usually from prac- 
tices against nature. These initial scleroses are often 
supposed to be " piles," of which complaint is usually 
made. Split-pea-sized and firm papules are then visible, 
usually one only, just beyond the anal verge, and the 



1/6 SYPHILIS AND THE VENEREAL DISEASES. 

bubo of the vicinity is distinguishable in the inguinal 
region or elsewhere. Other scleroses of this part are 
erosions and ulcers. The star-shaped ulcer of the soft 
chancre of the anus is never imitated by the syphilitic 
sclerosis, by reason of the failure of auto-inoculabil- 
ity. Chancres within the verge of the anus are rarely 
seen. 

The early perianal lesions of systemic syphilis are 
usually, and especially in the case of young adults, flat 
papules, springing or not from macular lesions. These 
may be discrete or confluent, in the latter event produ- 
cing a .perianal zone of infiltration with a dull redness 
that might lead the inexpert to suppose the case to be 
one of eczema, especially when, as is often the case, the 
lesions of this region are the seat of a considerable pru- 
ritus. 

In consequence of heat, moisture, and friction, these 
papules have a uniform tendency to flatten and to fur- 
nish a secretion. In this way miliary and (more often) 
lenticular papules, condylomata, elevated mucous patches 
and mucous plaques, verrucous growths, and other 
hypertrophic lesions develop about the anal orifice. As 
a consequence of their softness they readily break down 
into fissures radiating- from the anus, and even into 
formidable ulcers. The secretion they furnish is com- 
monly exceedingly foul. Many of the widely variant 
hypertrophies once known under the misleading title of 
" lupus of the vulva " (csthiouiene) are papillomatous 
growths about the anus as large as an ^gg and larger, 
beginning in an overgrowth of flat moist papules of this 
region. As these lesions are rapidly developed, so in 
favorable cases and with the best of treatment they can 
be made to disappear speedily. 



SYPHILIS OF THE RECTUM AND THE ANUS. IJJ 

More minute ulcerations occur at the verge of the 
anus, usually multiple, reddish or grayish in hue, oval 
and elongated, rarely circular, not very painful, and dis- 
covered perhaps by the physician engaged in making a 
careful search for lesions. With reference to some of 
these, a doubt exists as to their exclusive origin from the 
infectious disease present. They are seen in persons 
who have never been infected, and they are discovered 
with surprising frequency, by practitioners who habitu- 
ally make examinations of the anal region, in all classes 
of all subjects after middle life. A line of demarcation 
is drawn between these and the other ulcers of syphilis, 
in the fact that with exceedingly few exceptions simple 
ulcers never produce the formidable ravages to which 
almost every syphilitic loss of tissue at times succumbs. 
The really serious destructions of tissue about the anus 
are produced' chiefly by the chancroid. 

Tuberculous ulcers of the anal region, to which for 
a long period the title " tuberculosis of the skin " was 
practically limited, are wholly different from the minute 
lesions described above. The tuberculous losses resem- 
ble rents or tears of the tissue ; they have sharply cut 
walls, deep floors looking like clefts, and are as irregu- 
larly outlined as if cut at random. Syphilitic ulcers of 
this region are circular in outline and have undermined 
walls and pultaceous floors. Multiple tuberculous ulcera- 
tion of the rectum always occurs in connection with other 
symptoms of tuberculous disease. 

Gummata of the Rectum. ("Ano-rectal syphiloma ;" 
Syphilitic stricture of the rectum). — Several processes 
have been described in connection with gummatous 
changes in the rectum, and there have been given to the 
resulting deformities of this organ names which distin- 

12 



178 SYPHILIS AND THE VENEREAL DISEASES. 

guish merely different phases of one disorder. The 
simplest consideration of the subject is that which 
traces the career of a single process in these several 
manifestations. 

Gummata develop in the rectum as smooth, circum- 
scribed bodies set in the mucous or submucous tissue. 
They may be single, multiple or exceedingly numer- 
ous, or diffuse in two significant directions. In the one 
the area of development occupies a district more or 
less parallel with the long axis of the gut. In this event 
contracture of the infiltrated tissue does not involve co- 
arctation of the rectal walls. In the other case the gum- 
matous involvement occurs in an annular form, encir- 
cling the rectal pouch usually between two and three 
inches from the anus. In the latter event contracture 
of the gummatous mass acts in the same manner and 
direction as a sphincter muscle, and induces coarctation 
of the walls of the rectum. All the phenomena of 
stricture of the rectum may result from this annular 
gummatous change in the intestine, and the " ano-rectal 
syphiloma " of certain French authors is thus produced. 

The questions arise whether every stricture of the 
rectum is consequent upon gummatous changes, and 
also whether every stricture of the rectum, as has been 
believed, is due to syphilis. 

With respect to the first question, it is clear that while 
every syphilitic stricture of the rectum is practically due 
to gummatous infiltration of the rectal walls, it by no 
means follows that the beginning of the mischief lay in 
gummatous change. Early in the history of most cases 
there is a record of uneasiness at stool and perhaps 
of blood-smeared faeces, indicating that some local 
lesions, possibly erosions or superficial ulcers, had ex- 



SYPHILIS OF THE RECTUM AND THE ANUS. 1 79 

isted before the more serious change occurred. The un- 
fortunate part of such histories is the rarity with which 
the expert explores the rectal pouch before gummatous 
infiltration can be demonstrated. The second question 
can be dismissed with some certainty, even in the face 
of dogmatic assertions to the contrary. Syphilis is the 
cause of the majority of all cases of stricture of the 
rectum. But this serious disorder may also result from 
the contraction induced by chancroids of the same part, 
and it is probable that it may also result from tubercu- 
losis and other changes in the same organ. A few trau- 
matic cases are on record. 

When an annular gummatous band constricts the rec- 
tum, it produces a fibrinous change in the wall of the 
gut, the contracture of which, whether there be or not 
antecedent changes in the mucous membrane, sets up a 
proctitis liable to result in such changes. It has been 
seen that in certain organs, notably the liver, an unques- 
tioned gummatous deposit may result in a very firm and 
contractile fibrosis. This is what happens in the rectum. 
In some of these gummatous involvements the fibrous 
metamorphosis of the walls of the rectum is so com- 
pletely annular in its direction that a steadily increasing 
contraction occurs in the grasp of the ring, encroaching 
more and more upon the calibre of the gut. By inter- 
ference with the excretion of the intestinal contents, 
and by inducing a catarrhal condition of the bowel above 
the coarctation set up by such interference, one of the 
^gravest and most menacing of the complications of 
syphilis in the human body is eventually established. 

On digital exploration the milder cases suggest to the 
touch that the mucous surface is merely thickened ; at 
times both increase in thickness and roughening of the 



l8o SYPHILIS AND THE VENEREAL DISEASES. 

inelastic surface can be appreciated. Later the finger 
encounters an annular and sensitive band, dense in struc- 
ture, unyielding, and varying with respect to the size of 
the usually central aperture which it surrounds, the 
latter being at times sufficiently pervious to admit the 
tip or the entire thickness of the digit; or the gut 
may be so occluded as to furnish no perceptible open- 
ing. The free edge of this strictured portion is usually 
sharp to the touch. The commonest complications 
are papillomatous and other growths, with ulceration 
of the mucous surface of the rectum and dilatation 
of the pouch above the stricture. Very constant of 
occurrence are peculiar lobulated or tongue-like growths 
about the anus [languettes), in many cases wholly ex- 
ternal to the gut, usually numerous, and due to con- 
gestion of the parts below the site of constriction. 
These growths are almost pathognomonic of the disease. 
Hemorrhage, prolapse of the fundus of the bladder, and 
constant dribbling of urine are also symptoms of ex- 
treme distress in women, that sex furnishing by far the 
largest number of all patients. There is usually a stead- 
ily increasing sense of weight in the pelvis, and after 
ulceration painful defecation, with either flattened stools 
or liquid evacuations, the sole relief of the intestinal ob- 
struction occurring as the result of a diarrhoea. 

The diagnosis is to be made between the lesions of 
the rectum produced by syphilis, chancroid, carcinoma, 
and tuberculosis. For the most part, the history of the 
patient and microscopical examination are required in 
order to ascertain the facts. 

" Proliferating syphilitic rectitis " {rectite proliferante 
syphilitiqiie of the French) is a term used to designate 
the form of rectal disease in syphilis characterized by 



SYPHILIS OF THE GENITO-URINARY ORGANS. l8l 

unusual hypertrophic growths in the form of vegetations 
and nodules on the rectal membrane. 

Syphilis of the Genito-urinary Organs. 

In Men. — The penis is the frequent seat of the 
initial scleroses of syphilis, of all consecutive lesions of 
the same disease, and of gummata which ulcerate and at 
times produce extensive ravages of both cutaneous and 
subcutaneous tissue. These lesions have heretofore 
been described in these pages, as have also the chancres 
of the infected occurring after exposure to fresh sources 
of disease. When gummata develop in the corpora 
cavernosa, they are represented by pea- to larger-sized 
nodules, interfering with perfect erection of the organ. 
Very rarely annular bands form about the pendulous 
portion of the penis, distinctly circumscribed, and sug- 
gesting by their firmness the presence of a metal ring. 
The chancre situated at the tip of the urethra, accom- 
panied by a sero-purulent discharge and liable to be 
mistaken for a blennorrhagia, has also been described. 
Deeper gummatous deposits in the urethra and at the 
base of the penis are quite rare. Syphilis of the pros- 
tate gland and of the seminal vesicles is said to occur, 
but in the few rare cases reported no positive knowledge 
is had respecting the characters of the disorder. 

Gummatous deposits in the epididymis and the cord 
are decidedly more common than is generally supposed. 
Both early and late in the disease the globus major (much 
more rarely the globus minor) of the epididymis be- 
comes indurated, inelastic, and at times somewhat 
tender. When thus affected, the nodule has been com- 
pared by an English writer to the condition which might 
be recop:nized if an iron nut were screwed fast over the 



I 



1 82 SYPHILIS AND THE VENEREAL DISEASES. 

upper part of the testicle. One or both testicles simul- 
taneously may be involved, the distinctly circumscribed 
firm mass being readily recognized on palpation. A 
pachyvaginalitis also occurs with serous effusion in the 
sac of the tunica, exactly simulating the hydrocele of 
simple cases. Blood, pus, or serum may be found on 
exploratory puncture, and the indurated mass of the 
gummatous area may be discovered behind. Gumma- 
tous changes in the cord, circumscribed and diffuse, also 
occur where the epididymis has been, in whole or in 
part, the seat of the same trouble. 

Syphilitic orchitis is among the frequent complications 
of late syphilis, the gummatous change occurring very 
insidiously, often without any knowledge whatever of 
the change on the part of the patient. This condition is 
so frequently discovered for the first time by the phy- 
sician in his examination of the patient that it is wise 
in all cases of gummatous changes recognized else- 
v/here (bones, subcutaneous tissue, nervous system) to 
examine with a special view to the recognition of disease 
of the testicle. 

When the body of the testis proper is attacked, 
fibrosis (as of the liver, already explained) or gummatous 
infiltration may ensue, and the latter in either circum- 
scribed or diffuse form. A part or the whole of one or 
of both glands may be involved ; often the nodular ele- 
vations of the surface of the gland may be recognized 
by palpation. In other cases the dense induration of the 
testicle may be determined with accuracy by the touch 
and by its well-defined limitations, but the tissue is quite 
smooth and has the feeling of marble. The gland may 
be unaltered in size or more voluminous than normal, 
attaining in extreme cases the size of the largest orange. 



SYPHILIS OF THE GENITO-URINARY ORGANS. 1 83 

The apparent increase in size may be due to an accom- 
panying hydrocele. When resolution occurs, the gland 
may slowly diminish in size by the absorption of the 
sclerotic or gummatous mass, and, as the deposit has 
usually squeezed the secreting cells of the organ to 
the point of destruction, the ultimate result is the 
shrivelling of the testicle to a diminutive miniature of 
its former self, as after the occurrence of mumps of the 
same gland. In other cases the gumma degenerates, 
attachments form between the gland and the scrotal en- 
velopes, softening occurs at a central point, and the 
gumma bursts with the subsequent production of ulcer- 
ation and fistulous connection of the testicular mass 
with the integument of the scrotum. At times, as a 
consequence of the contractility of the muscular and 
other parts not affected, the parenchymatous tissue is 
forced through the scrotal opening until " benign fungus 
of the testicle " results — a condition until lately not well 
understood. 

In the matter of diagnosis gonorrhoeal epididymitis so 
commonly affects the globus minor that a distinction 
between it and a syphilitic change is usually readily 
established ; but it is not to be forgotten that in both 
disorders the location of the lesion may be different. 
Tuberculosis of the testicle commonly begins with in- 
volvement of the prostate, and it is a malady wellnigh in- 
variably of those who are not victims of venereal disease. 
In syphilitic affections of the scrotum the lesions are 
those of the general surface of the integument, changes 
in their aspect being due to friction, motility, heat, and 
other accidents of the location. 

In Women. — In the genital region of women, as 
well as in that of the male sex. the initial scleroses 



184 SYPHILIS AND THE VENEREAL DISEASES. 

and consecutive lesions of syphilis are common. Chan- 
cres of women are not often recognized, by reason of 
their hidden position within the vulvar portal. The late 
gummatous lesions of this part should be distinguished 
from the condition long termed " lupus of the vulva " 
(estJiioniene of Huguier). Under this title have been 
described gummatous lesions of the vulva, in which 
category are to be classed both circumscribed and dif- 
fuse indurations, hypertrophic growths (as in strictures 
of the rectum and due to the same cause, tongue-like 
langnettes, and otherwise shaped papillomatous masses), 
and ulcerations with ragged edges destroying in whole 
or in part the ostium vaginae and invading the region of 
the perineum and the anus. The frequent firm cedema 
of the vulva is supposed to be due to changes apart 
from the syphilitic process. Cancer of this region, espe- 
cially of the clitoris, is to be excluded in establishing a 
diagnosis, as is also Breisky's " kraurosis of the vulva," 
a rare disease accompanied by contraction of the parts. 
Tuberculosis of the vulva is exceedingly rare, and it 
probably occurs with even greater rarity dissociated from 
vaginal lesions. 

Syphilis of the vagina, if not rare of occurrence, is 
rarely observed. Chancres and consecutive lesions are 
inapt to form in the vaginal walls, and even when these 
are implicated in gummatous changes the morbid process 
usually spreads to this mucous surface from others in the 
vicinity. The urethra of women may be the site of chan- 
cres and early and late lesions of the disease ; in very 
rare cases stricture results from gummatous involvement 
of the submucous tissue, especially in long-standing 
cases of syphilitic stricture of the rectum. The mucous 
surface of the cervix and of the os uteri is the seat of 



SYPHILIS OF THE GENITO-URINAR Y ORGANS. 1 85 

both chancre and consecutive lesions more often than is 
generally supposed ; the former have previously been 
described. Mucous patches and other consecutive lesions 
of syphilis in this region, in their appearance and evo- 
lution, scarcely differ from those seen within the oral 
cavity. Care should be observed, in formulating a diag- 
nosis, not to confound epithelioma of the os, polypus, 
and chancroid with the lesions of syphilis. The affec- 
tions of the womb, ligaments, tubes, and ovaries due to 
syphilis are rare, and careful investigation of the subject 
is wanting. 

The bladder is rarely the seat of either early or late 
syphilitic lesions. Proksch is almost alone in his re- 
searches on the subject of gummatous changes in the 
vesical walls, with ulceration and the formation of a 
sinus connecting the gummatous nodule with the vesical 
cavity. Two cases have been observed by us ; in one 
case a papillomatous growth occurred as a result of 
syphilitic changes in the wall of the bladder (revealed 
by suprapubic cystotomy) ; in the other, a man sixty- 
two years of age, there had been hypertrophy of the 
prostate before infection, and a gummatous mass devel- 
oped within the gland, reaching into the fundus of the 
bladder. 

Syphilis of the Kidney. — The early changes in the 
kidney due to syphilis may occur within a few months 
after infection, the symptoms being those of an acute 
nephritis with slowly or more rapidly developing oedema 
of the face and the limbs, dysuria, frequency in voiding 
the urine, headache, backache, and profound asthenia. 
Albumin, blood, epithelium, blood-corpuscles, and casts 
may all be present in the urine. Under vigorous treat- 
ment these patients almost universally recover, even 



1 86 SYPHILIS AND THE VENEREAL DISEASES. 

when the danger seems extreme. The organ is found 
enlarged in most cases, the cortical portion is increased 
in relative size, and the tubules are blocked with epi- 
thelial debris and colloid masses. The glomeruli ex- 
amined with the microscope may exhibit the same catar- 
rhal state or be normal in appearance. 

In the late lesions of the kidney there is found, as in 
the liver, a species of fibrosis (" interstitial inflamma- 
tion") with resulting contracture and pressure-effects 
upon the glomeruli, or gummatous deposits, circum- 
scribed or diffuse, the latter rather more rarely. As a 
consequence of either process amyloid or fatty degenera- 
tion may occur, in rare cases, simultaneously in the same 
organ. The lardaceous kidney of syphilis is large and 
white and unilateral or bilateral. At times good re- 
covery ensues where but one organ was probably in- 
volved. The same is true of gummatous changes. In 
both conditions the urine may contain albumin, blood, 
casts, epithelium, and even pus-cells. Usually the cor- 
tical and pyramidal portions of the kidney are involved. 
There is strong reason to believe that gummatous 
changes in the kidney in syphilis are of greater frequency 
than is suspected, many patients recovering from even 
severe renal symptoms without grave results. It is to 
be remembered also that many of the renal changes 
minutely described in the treatises on pathology are 
supposed by modern authors to be indirectly due to 
syphilis. The prognosis is grave when both organs are 
involved and amyloid degeneration has taken place; 
syphilitic changes in one kidney or in a portion only of 
one are to be regarded with greater hopefulness. We 
have watched for fifteen years, after grave syphilitic in- 
volvement of the kidney, patients who suffered from no 



SYPHILIS OF THE NERVOUS SYSTEM. 1 8/ 

return of renal symptoms. Surgical removal of a single 
kidney found to be affected with syphilitic changes has 
been followed by recovery. 

Syphilis op the Nervous System. 
Syphilis both early and late in its career affects the 
nervous system, the earlier manifestations being, for the 
most part, reactive, without appreciable lesion, and due 
chiefly to the circulation in the system of intoxicated 
blood. Late lesions of the nervous system may occur 
from a few months to several years after infection, and 
may result from syphilis of the osseous system, pro- 
ducing indirectly pressure or other injurious effects upon 
the nerves or the nervous centres in anatomical rela- 
tion with the bones ; or from syphilis of the menin- 
geal coverings of the nerves, with effects not widely 
different from those exhibited when the bones are in- 
volved ; or from syphilis of the nervous cells and fibres, 
or from syphilis of the larger vessels furnishing nutrient 
material to the nerves. Gummatous deposits may be 
responsible for the symptoms present in any of the 
several complications named, the evolution and subse- 
quent history of the neoplasm having already been 
described. In one or another of these several forms 
syphilis of the nervous system occurs more often in 
male than in female patients, for the reason commonly 
accepted — that men are, as a rule, more than women 
subject to mental care and physical fatigue in business 
and toil. By some authors the nervous system is 
credited with the larger number of all the so-called 
"late" or "gummatous" changes noted in syphilis — a 
proportion, however, that is chiefly conspicuous in the 
statistics of experts in nervous maladies. Certain it is 



1 88 SYPHILIS AND THE VENEREAL DISEASES. 

that women as well as men suffer severely from the 
nervous complications of the malady; and, inherited 
disease excepted, it is probably true that a fatal issue in 
syphilis can more often be ascribed to the nervous sys- 
tem than to any other. The importance of the recogni- 
tion of nervous syphilis and the pressing need of its 
appropriate therapy can scarcely be exaggerated. 

Syphilis of the Brain and of the Cranial Meninges. 
— In brain-syphilis the effective lesion may be related 
to any one of the conditions noted above. The com- 
monest localization is in the cortical portion of the 
brain, a gummatous deposit, either circumscribed or 
diffuse, directly or indirectly implicating the meninges. 
Meningo-encephalitis involving extensively one or both 
hemispheres, or a portion only of the nervous structure 
at one or several points, may result in varying grades of 
resulting damage. When an endarteritis obliterans (or, 
more rarely, a mesarteritis or a periarteritis) occurs, the 
injury is by thrombosis and subsequent occlusion, or by 
the formation of small aneurysms as in syphilis of the 
blood-vessels, or by dislodgement of one or more frag- 
ments of an embolus and their later transference in the 
blood-current to points at a distance from a forming 
neoplasm. For the localization of the nervous lesion by 
the aid of the symptoms in any case presented, the 
student is referred to the results of the admirable studies 
of this theme presented in the works on general pa- 
thology. Collectively, the symptoms may be described 
as, first and most common, headache, usually character- 
istically severe, of a boring, hammering, constricting, or 
grinding character, generally with very distinct nocturnal 
exacerbation, accompanied or not by vomiting, and at 
times terminating in relief in the most capricious man- 



SYPHILIS OF THE NERVOUS SYSTEM. 1 89 

ner. This pain may be aggravated by percussion or 
pressure over certain points of the cranium, and often is 
marked along the hnes traced by the distribution of the 
trigeminus. A striking feature of all these disorders is 
the multiformity of the symptoms present and their 
capriciousness as to grave or insignificant results. Thus, 
symptoms of coma or of paralysis may appear or dis- 
appear in a way utterly impossible without grave se- 
quence in any non-syphilitic disease. The multiformity 
so characteristic of the surface symptoms of the disease 
is often striking when the nervous system is attacked. 
Mental hebetude, stupor, coma of insidious beginning, 
convulsions, or a seizure simulating that of epilepsy, but 
different from it in that the average patient does not 
wholly lose consciousness, may each be significant. Of 
equal importance may be named hemianopsia, motor or 
sensory aphasia, disturbances of olfaction or of taste, per- 
sistent dilatation of one pupil, or paralysis of a single 
muscle or of a capriciously selected group of muscles 
within the orbit. 

When syphilis affects the larger ganglia, the gumma- 
tous deposit is less likely to be implanted in the nervous 
tissue proper than in the walls of the larger vessels, 
especially those of the middle cerebral artery, the com- 
plete or even partial occlusion of which by an obliterat- 
ing arteritis is apt to be followed by a monoplegic or 
hemiplegic attack, the consequences of which may be 
serious. Here the onset of the disease may be insidious 
and unaccompanied by the chain of symptoms of brain- 
syphilis ; or all these may be present, with severe head- 
ache, mental hebetude, and even coma. As a rule, 
however, the patient suffering from a syphilitic hemi- 
plegia is entirely conscious, and, though for weeks 



1 90 SYPHILIS AND THE VENEREAL DISEASES. 

previous the victim of an agonizing cephalalgia, is re- 
lieved of most of the cranial distress when motor paral- 
ysis is established. The reflexes of the wrist, of the 
elbow, of the knee, and of the ankle are usually exag- 
gerated in the paralyzed extremities both after and before 
the seizure. It will be remembered that in consequence 
of decussation of fibres, the gummatous changes of one 
side of the brain are for the most part responsible for 
paralytic phenomena of the other. Recovery may be 
relatively rapid in the course of a few weeks, or it may 
require years for its completion. In some cases the 
damage done is irreparable, and contractures result in 
both upper and lower extremities ; the speech becomes 
mumbling, and the patient, while life is yet conserved, 
reaches in almost every function of the body one of the 
lower levels of physical degradation. ** 

Lesions of the crus are apt to be betrayed in oculo- 
motor paralyses associated with hemiplegia of the other 
side of the body, while those of the pons are liable to be 
followed by facial paralysis in which the arm and the 
leg of the opposite side are involved. In the case of 
affection of the medulla there is often a similar associa- 
tion of paralyses — a hemiplegia of one side and an in- 
volvement on the other of the vagus, glosso-pharyngeal, 
hypoglossal, or other nerves whose nuclei have a medul- 
lar site. There may be also a bilateral palsy of the four 
extremities, the result depending upon the extent of 
gummatous change in the meninges. 

Paralyses of the oculo-motorius are so frequent in 
syphilis that their occurrence always leads to special in- 
quiries on the part of the careful diagnostician respecting 
a possible syphilitic origin. The third, sixth, and fourth 
nerves (most commonly the two first named) may, when 



SYPHILIS OF THE NERVOUS SYSTEM. 



191 



affected, produce ptosis, paralysis of the superior oblique, 
external and internal recti, and failure of accommodation 
to light. The capriciousness with which one or more 
of the muscles innervated by these trunks are selected 
for attack is highly characteristic of syphilis. 

Syphilis of the Cord and of the Meninges. — The 
symptoms of syphilis of the cord and its coverings are 
spastic paralysis of both lower extremities, involuntary 
action of the rectum and the blacider, exaggeration of 
some or all of the tendon reflexes, contractures of mus- 
cles, particularly of the adductors of the thighs, more or 
less anaesthesia, a tendency to the formation of bed-sores, 
and, in cases, pains of a severe character in the loins and 
the lower limbs. These changes may result from gum- 
matous deposits in the vertebrae or in the meninges of 
the cord, or from a distinct specific myelitis or meningo- 
myelitis occurring in the cervical, dorsal, or lumbar 
region, one or all. Other symptoms which may be 
present in exceptional cases are changes in the ocular 
system (for example, persistent dilatation of one pupil), 
in the genital system (increased or diminished sexual 
desire and vigor), and paralysis limited to wrist-drop of 
both upper extremities, to cephalalgia, to aphasia, etc. 

The etiological relation of syphilis to tabes has been 
the fertile source of a controversy which has at last been 
settled by an overwhelming preponderance of testimony, 
derived, for the most part, from evidence furnished not 
so much by syphilologists as by the statistics of insane 
asylums. Syphilis is without question a precedent fact 
in more than 90 per cent, of all cases of tabes. Patients 
of this class are, however, in the category of those little 
benefited by treatment for specific disease. Here, as in 
other ailments following infection, it seems that the 



192 SYPHILIS AND THE VENEREAL DISEASES. 

result is less directly due to the toxic agents of the 
malady than to some chain of factors set in operation by 
the syphilitic germ. 

The symptoms of tabes dorsalis in syphilis and in a 
presumably small minority where syphilis has at least 
not been proven are the Same, and for a description of 
these symptoms the reader is referred to treatises on 
general medicine. Care should always be taken, in 
establishing a diagnosis, to avoid setting down as symp- 
toms of syphilis those due to other changes in the cord ; 
as, for example, when there is a loss of one or more bones 
of the digits of the feet, or when from the same cause 
the nails are exfoliated. 

Cerebro- spinal syphilis (multiple cerebro -spinal 
syphilis) is a term employed to indicate those cases in 
which there is simultaneous involvement of both brain 
and cord. The number of these cases is larger than is 
commonly believed. 

Dementia Paralytica and other Mental States due 
to Syphilis. — It is exceedingly difficult to ascribe to the 
proper cause the many singular and diverse mental 
states recognized in syphilitic subjects. It is to be re- 
membered that of a thousand victims of infection a cer- 
tain proportion were before the accident predisposed 
strongly, from other influences (heredity, accident, etc.), 
to nervous disease, and that many others, during the 
long course of treatment required for the relief of syph- 
ilis, are exposed to numerous influences tending to in- 
duce mental states of a morbid character (business re- 
verses, affliction, accidents). It is not very rare to find 
grave states of hypochondria leading to self-destruction 
in a certain class of young subjects of both sexes after 
infection ; and transient dementia is occasionally en- 



SYPHILIS OF THE NERVOUS SYSTEM. 1 93 

countered, with and without hallucinations and stupor. 
In these cases, as Sachs has shown, very remarkable 
intermissions and recovery stamp the disorder as due 
only to lues. The persistent dementias which prove 
complete are, fortunately, rare in syphilis. They usually 
follow the graver lesions of the nervous centres. 

Demejitia paralytica of the alienists {delire des gran- 
deurs, general paresis), with epileptiform and apoplectic 
seizures, mental hebetude leading to failure of almost 
all the mental faculties, pupillary inequalities, tremor 
in articulating (lips and tongue), with singular changes 
in the moral qualities of the individual, is, like tabes 
dorsalis, amply delineated in the descriptions to be 
found in the best works on nervous diseases. To-day 
there is no question in the minds of the experts of 
large experience, chiefly those engaged in institutions 
for the insane, that syphilis is a precedent fact in a great 
majority of all cases. As in the instance of tabes, the 
infective process seems to be rather an indirect than a 
direct cause of the issue. The frequent relation of tabes 
with dementia paralytica would alone suggest the syph- 
ilitic origin of the last-named disorder, even if statistics 
were not at hand to confirm the fact. 

Syphilis of the Peripheral Nerves. — The cephalalgias 
of nervous syphilis are, without question, at times rep- 
resented by neuralgias due to specific involvement of the 
peripheral nerves. "Syphilitic sciatica" is as distinctly 
a symptom of a condition recognized in the subject of 
lues as is nocturnal cephalalgia ; and cases are recorded 
in which gummata of bone and of other tissues in the 
tract of a nerve-trunk have by compression or other 
accidents induced serious changes in the nerves them- 
selves. 

13 



194 SYPHILIS AND THE VENEREAL DISEASES. 

Syphilis op the Eye and Ocular Appendages. 

The lachrymal g-land is rarely involved either in a 
primary gummatous infiltration or secondarily as a result 
of implication of other organs in the orbit. The same is 
true of the lachrymal cai'iincle, which may become tumid, 
engorged, dense, and eventually the site of ulceration in 
the rare cases in which it has been found diseased. The 
canalicidi^ the puncta, the sac, and the Jiasal duct may be 
involved in any one of the early or late manifestations 
of syphilis when the eye is involved, usually as the 
result of some lesions in the vicinity, as, for example, 
chancres, papules, tubercles, ulcers of the edges of the 
lids, iritis with its frequent accompaniment of conjunc- 
tivitis, and the panophthalmias seen in filthy and des- 
titute charity patients in dispensary practice. Again, 
many of the syphilitic lesions of the nasal passages lead in- 
directly to catarrhal and purulent inflammatory affections 
of the sac. Periostitis of the bones forming the nasal 
cavity is a frequent source of these purulent catarrhs. 
Stricture and eventual obliteration of the duct may 
result either from gummatous deposits in the mucous or 
submucous tissue or from osteo-periosteal changes in the 
channel. The external symptoms of these affections are 
epiphora, a swelling of the part, and tenderness with a 
sense of fulness. There is commonly evacuation of a 
sero-purulent fluid when pressure is exerted over the 
tumor. Eventually there may be abscess and ulceration 
at the point of bursting. The osteoplastic metamor- 
phosis of the bony walls of the canal, described hereto- 
fore as eburnation (one of the varieties of formative 
osteitis), occasionally occludes the duct by the formation 
of a growth which chokes its calibre; but more often 



SYPHILIS OF THE E YE AND OCULAR APPENDAGES. 1 95 

the bony changes here are in the hne of caries and 
necrosis, reheved by spontaneous or artificial removal of 
segments of bone. 

Syphilis of the eyelids may be exhibited in chancres 
or in the syphilodermata of systemic disease, such lesions 
being located either on the edge, on the conjunctival 
surface, or on the cutaneous covering of the lid. In the 
case of chancre the diagnosis is readily made when con- 
sideration is had of the induration of the lesion and its 
bubo, the enlarged gland being usually the pre-auricular 
of the involved side. Eyelid-chancre has the usual 
characteristics of chancres seen elsewhere and pre- 
viously described, the chief peculiarities of the site being 
an enormous tumefaction of the lid that occasionally 
(not invariably) results, and the consequent epiphora and 
photophobia. When the initial sclerosis ulcerates, the 
excavation is shallow and oval, with elevated edges, 
densely sclerosed base, and a floor secreting rather more- 
freely than chancres in other situations, on account of 
the irritation to which it is subjected. 

Syphilodermata are more frequently found on the 
cutaneous surface of the eyelid; rarely an isolated 
lesion or several lesions may be discovered on the 
conjunctival surface; but in our experience these 
accidents result most commonly from special causes 
inciting the mucous membrane to morbid activity (trau- 
matism, iodism, foreign bodies beneath the lid). Gum- 
^ mata, when present, form nearer the free border of the 

■ lids than elsewhere ; they may be single or multiple in 
B this region, and their ulcers, when they degenerate, are 
K characteristic. When the tarsus is infiltrated with a 
B gummatous deposit, a firm tumor results, implicating the 

■ entire hd (usually the upper) or but a portion of it, with 



196 SYPHILIS AND THE VENEREAL DISEASES. 

and without involvement of the cutaneous surface. Here, 
as in syphilis of the testis and the liver, after complete 
absorption of the neoplasm has been effected the tarsus 
may lose its original texture and elasticity. 

The conjunctiva may be the seat of any one of the 
processes previously described in connection with syph- 
ilis of the mucous membrane, save that the limitations 
of the area involved and the large portion of it that is 
protected by apposition of contiguous surfaces save it 
from many of the sources of disease to which the lining 
membrane of the mouth and of the nares is especially 
subject. Chancres of the conjunctiva have been reported 
without implication of the lid, but they are exceedingly 
rare. Papules, tubercles, pustules, and ulcers occur upon 
the conjunctiva as elsewhere, and are readily recognized 
by the symptoms heretofore described. Ulceration of 
the conjunctiva, whether from breaking down of a 
gumma or as the result of pustulation of the surface, 
produces one or many points where superficial losses of 
tissue occur, circumscribed, with uneven base, covered 
usually with a more or less adherent yellowish-white 
film, beneath which the surface is eroded. On the free 
edge of the lid the ulceration often assumes a linear 
shape and spreads along the entire edge, excavating its 
thickness. Cases are recorded in which gummata of 
the ocular conjunctiva produced an annular infiltration 
surrounding the cornea, which, after degeneration of the 
former, has undergone necrosis. 

Syphilis of the cornea occurs either in the form of an 
interstitial keratitis, with points of opacity usually at first 
centrally situated, spreading thence outward and involv- 
ing the deeper layers, which may become vascularized ; 
or the opacity spreads from the periphery to the centre. 



SYPHILIS OF THE E YE AND OCULAR APPENDAGES. 1 97 

and eventually produces the characteristic "ground- 
glass " appearance of the cornea. In another form there 
are definite points of opacity, the puncta being pin-point 
to pin-head in size, usually not numerous though multi- 
ple, the transparency of the unaffected portions of the 
cornea being unaltered. Gummatous deposits in the 
cornea, of the type of the gumma of other regions, have 
occasionally been observed. 

Syphilis of the sclerotic is betrayed in superficial and 
parenchymatous forms of scleritis, some authors describ- 
ing a gummatous form as distinct from the latter, the 
difference in all being, however, one chiefly of external 
appearance of the lesion. In the milder cases dark- 
tinted, even empurpled patches occur, of congestive 
aspect, with thickening of the tissues and obvious in- 
volvement of the overlying conjunctiva. These maculae 
may be single or multiple; they are rarely ve'ry numer- 
ous, and are said never to form a pericorneal zone, 
though extreme cases occur where the deep congestion 
involves a large part of the exposed sclera. There is 
usually some pain, although at times none is experienced. 
Iritis is rarely present. In the parenchymatous form all 
the symptoms above described are exaggerated and com- 
plications are more common. The disorder is really a 
diffuse gummatous change, as distinguished from the 
circumscribed forms of gummatous deposit, in which 
elevated or flattened nodules, usually developing on the 
temporal side of the globe, exhibit telangiectases over- 
lying the conjunctiva. 

Syphilis of the iris is the most common of all luetic 
affections of the eye. Iritis, acute, subacute, or chronic, 
occurs both early and late after infection, much more 
often seen after the involution of the chancre. Usually 



198 SYPHILIS AND THE VENEREAL DISEASES. 

but one eye is affected, rarely both. Recurrences are 
apt to be limited to the organ originally involved. In 
our experience there is usually an exciting cause even 
when syphilis is present, determining the onset of the 
affection and even its selection of a weak eye. For ex- 
ample, there are few experts in the cities of the North 
who have not noted an increase in the number of cases 
of iritis in a group of syphilitic patients treated after the 
streets have suddenly been covered with snow. Forms 
of plastic, serous, and gummatous iritis are described by 
authors, the three forms being distinguished merely by 
a preponderance of one or more symptoms present in 
any given case. The chief symptoms regularly noted 
on the part of the patient are photophobia, lachrymation, 
deep-seated pain, and imperfect vision ; while the physi- 
cian recognizes tumefaction and a change of color in 
the affected iris; irregularity of the pupillary opening, 
due, as a rule, to posterior synechiae, giving an oval, at 
times even a jagged, outline to the pupil ; marked slug- 
gishness of the iris when light is suddenly admitted to 
it; and deep ciliary injection, distinguished by radii of 
straight pinkish vessels forming a halo about the cornea 
and contrasting vividly v/ith the longer, more tortuous, 
and brick-colored vessels set superficially, deeply en- 
gorged, and belonging to the conjunctiva. In the forms 
of serous iritis of authors the aqueous humor is turbid, 
the tension of the eyeball is increased, and the field of 
the pupil, especially near the margin of the iris and the 
posterior face of the cornea and of the iris, becomes the 
seat of exudative deposits. The term " gummatous 
iritis " is by some authors limited to the distinct forma- 
tion of nodes, papules, or reddish-yellow tubercles on the 
surface of the iris ; but it is probable that all syphilitic 



SYPHILIS OF THE E YE AND OCULAR APPENDAGES. 1 99 

forms of iritis are due chiefly to gummatous deposits 
even when no circumscribed nodules appear on the an- 
terior face of the curtain. 

The prognosis of all forms of iritis is good. The chief 
danger arises from adhesion of the iris to the capsule 
of the lens as a consequence of posterior synechia — a 
complication which may usually be set aside by the pro- 
duction of extreme mydriasis. Glaucoma results in a 
very small proportion of cases. 

Syphilis of the Ciliary Body. — Serous, plastic, and 
gummatous forms of cyclitis are recognized, the chief 
difference between them being the mode of gummatous 
infiltration, all being due to deposit of gummatous 
material either in diffuse or in circumscribed form. 
When the ciliary body is implicated the symptoms are 
the following: visual disturbance in various grades; 
usually, not invariably, diminished tension ; ciliary in- 
jection ; and an exudation varying in amount and cha- 
racter within the posterior chamber, and at times also 
involving the vitreous. Often the symptoms of iritis and 
of choroiditis are present, and the disease is then prop- 
erly described as " irido-choroiditis." In well-marked 
cases the attached portions of the iris are pushed for- 
ward by the vis a tergo of the exudate, blocking up the 
pupil and distending the posterior chamber, while its 
free border is more or less fixed by posterior synechiae. 
Glaucoma or softenins: of the globe may result, and the 
issue is, in general, grave. The gummatous material, 
whether deposited in points on the membrane of Desce- 
met or spreading to the ciliary body from nodules on the 
face of the iris, undergoes changes, either by resolution 
or by disintegration, not different from those recognized 
in other portions of the globe. 



200 SYPHILIS AND THE VENEREAL DISEASES. 

Syphilis of the choroid is more common than any 
luetic affection of the eye save iritis ; in point of serious- 
ness, while not so grave in the majority of cases as cyc- 
litis, the affection may result in irreparable damage. The 
symptoms are, in general, clouding of the vitreous humor 
by reason of exudates forming fixed or floating specks, 
fibrils, threads, membranes, or even, in extreme cases, 
semi-solid masses of irregular form occupying either the 
anterior or the posterior half of the choroid, and accom- 
panied or not by retinitis and disturbance of vision in 
various degrees. Iritis is a complication when the an- 
terior portion of the choroid is chiefly involved, retinitis 
when the posterior segment is affected. There occur 
rapid diminution of ocular tension, deep-seated pain, and 
amaurosis in various degrees of severity. The remote 
results of these serious changes are the formation of 
staphyloma, cataract, detachment of the vitreous, and 
ultimate atrophy and shrinkage of all the constituent 
coats of the eye. By the aid of the ophthalmoscope in 
well-marked choroiditis whitish-yellow or reddish-yellow 
patches, fairly well circumscribed, can be recognized 
about the posterior pole of the ocular axis, often with a 
distinctly pigmented halo and with a tendency to atrophy 
of the tissue in which they have developed. 

The crystalline lens and the vitreous humor, when 
attacked in syphilis, always exhibit nutritional changes 
secondary to morbid processes in the uveal tract. 

Syphilis of the retina furnishes a list of grave dis- 
orders as respects vision. Chorio-retinitis is practically 
a complication of choroiditis, as already described. 
When the retina is distinctly involved, a membranous 
film appears to be stretched between it and the observer. 
There is also scotoma and deficient central vision. The 



SYPHILIS OF THE E YE AND OCULAR APPENDAGES. 201 

forms of pure retinitis where the choroid is not involved 
are rare. By the aid of the ophthahnoscope it can be 
seen that the fundus of the eye is misty, the papilla is 
obscured, and the disk, which may be engorged, is en- 
circled by a grayish retina. The symptoms are hemeral- 
opia, lachrymation, photophobia, diminution of central 
vision, and the appearance to the patient of bright circles 
or patches which revolve about the point on which the 
eye is fixed. When a distinct exudation occurs the 
inner layers of the retina are involved and indistinctly 
circumscribed elevations occur chiefly about the poste- 
rior pole of the eye. When, as a result of these or 
of the other changes in syphilitic disease of the retina, 
hemorrhages occur, the symptoms and appearance are 
those of similar complications in non-specific disease. 
The " central recurrent retinitis " of Von Graefe is ex- 
hibited in opacities about the macula, which disappear 
at the time of the improvement of the vision, but which 
may return with the production of characteristic streaks 
radiating from the disk along the lines of the vessels. 

The optic nerve may be 'affected by syphilis either 
within the cerebral tissue, within the orbit, or between 
the orbit and the brain, and as a result either of morbid 
changes in the adjacent tissues (bones of the orbit or 
foramen) or of primary involvement of the nerve-tissue. 

Papillitis (inflammation of the intraocular extremity 
of the nerve) is betrayed by tumefaction of the disk 
(with its outline obscured by surrounding oedema), 
venous stasis, and arterial stenosis. When both eyes are 
thus affected, and they exhibit signs of choked disk, the 
diagnosis is of an intracranial lesion (gumma of bone, 
vessel, meninges). When but a single eye is involved, 
the source of the trouble may be wholly within the orbit. 



202 SYPHILIS AND THE VENEREAL DISEASES. 

There may be amblyopia, hemianopsia, or more or less 
complete amaurosis. Preservation of fairly good visual 
power with symptoms of choked disk is supposed to be 
due to the integrity of the layer of cones and rods in the 
retina. 

In neuritis descendens of one side the lesion obviously 
has existed between the chiasm and the orbit; when both 
sides are involved, the lesion is situated posterior to the 
chiasm. In these cases the change occurs primarily in 
the tissues outside the nerve-sheath, the latter being 
secondarily involved, as are also the nervous fibrillae 
within the sheath. The most common causes are arter- 
itis, mesarteritis, endarteritis, meningitis, and gummata 
of the encephalic nervous tissue. 

Atropliy of the optic nerve may result from any of the 
changes described above, or from encephalic or spinal 
disease. The differences between the inflammatory, 
cerebral, and spinal forms, as distinguished by the oph- 
thalmoscope, are chiefly color-changes in the optic disk 
from a grayish-blue to a bluish-green shade, and the 
various degrees of reduction in size of the arteries and 
the veins, the picture being more or less hidden by an 
obscuring mist. In some cases, however, no ophthal- 
moscopic changes can be recognized, and the location 
of the site of the effective lesion must be inferred from 
other symptoms. In hemiopia fugax (flittering scotoma) 
and true hemianopsia the lesion, without visible ophthal- 
moscopic changes, is probably seated in one optic tract. 

Syphilis of the ocular muscles has already been 
described in connection with the subject of nervous 
lesions. It is merely needful to repeat here that the 
great majority of all cases of disturbance of function of 
these muscles is due not to a specific myositis, but to 



SYPHILIS OF THE EAR. 20 3 

intracranial lesions (pachymeningitis, obliterating arterial 
disease, etc.). 

Syphilis of the bony walls of the orbit is exhibited 
in osseous changes of the types already described in 
connection with bone-syphilis, periostitis, osteo-perios- 
titis, hyperostosis, exostosis, caries, and necrosis, these 
conditions representing a series of changes due to the 
evolution of a gummatous product, its absorption or deg- 
radation, and the formative processes (by fibrosis, ebur- 
nation, etc.) already studied. As a consequence of these 
changes in the orbital bones, exophthalmos (protrusion 
of the eyeball outward, along its axis, or, as is not un- 
common, to one side) may result, with secondary con- 
sequences due to stretching and traumatism of the optic 
nerve. In other cases the nerve is injured by pressure, 
and atrocious neuralgias may follow. In yet other cases 
abscesses form and burst externally, at times with result- 
ing exfoliation of osseous sequestra, at others with the 
formation of fistulous tracts leading to carious bone. 
When exostosis occurs from the walls of the orbit, the 
tumor usually forms on the inner wall and projects 
toward the central axis ; but it may also develop near 
the apex and produce exophthalmos or grave pressure- 
effects. These growths as a result of syphilis are ex- 
tremely rare. 

Syphilis of the Ear. 

The auricle may be the seat of chancre or of any of 
the cutaneous lesions of systemic syphilis — macules, 
papules, pustules, tubercles, gummata, ulcers, etc. 

The meatus may also be found affected with any of 
the lesions occurring upon the auricle. Exceedingly 
intractable ulcerations occasionally progress just within 



204 SYPHILIS AND THE VENEREAL DISEASES. 

the meatus, at the junction of cartilage and bone. These 
ulcers greatly resemble the ill-conditioned ulcers often 
visible at the same time and in the same patient just 
within the nares. Condylomata are not rare within the 
meatus, where they may often be recognized as circum- 
scribed, scaling elevations of the surface, furnishing an 
admixture of pus and cerumen, in extreme cases event- 
ually inducing by their presence a typical otitis externa. 
Blocking of the canal may ensue, and in severe cases 
ulceration with scarring. Rarely there results per- 
manent contraction of the meatus. 

The mem bra na tyvipani is rarely the seat of syphilitic 
lesions. Luetic changes have, however, been recognized 
in this situation, and ulceration has at times resulted 
from degeneration of minute gummata situated upon the 
drum. 

The diseases of the tympanum due to syphilis are 
obscured by reason of the difficulty experienced in pre- 
cisely locating any lesions capable of producing the 
symptoms exhibited in any given case, and by the 
further fact that the symptoms presented are so nearly 
alike in the victims of both syphilitic and non-syphilitic 
aural disease. 

Catarrhal inflammatory affections of the middle ear 
occur, resulting in hypersecretion, pus-formation, or the 
formation of plastic products, the distinction between 
these affections being established by symptoms rather 
than by any recognized lesions. Most of these troubles 
are associated with or spring directly from disorders of 
the naso-pharynx, which is so frequently involved in 
systemic syphilis ; others arise from changes in the 
osseous walls of the Eustachian tube or from periostitis 
of the tympanum. The symptoms of these diseases of 



HEREDITARY SYPHILIS. 20 5 

the middle ear are chiefly deafness in varying degrees, 
pain, serous or purulent discharges, tumefaction to the 
point of obstruction of the Eustachian tube, and rales on 
its insufflation. 

The changes in the labyrinth due to syphilis are as 
yet little understood. The ossicles may be ankylosed, 
and all the tissues composing the labyrinth may be 
thickened either primarily or as a result of extension of 
disease from the tympanum. The symptoms are found 
in a series of widely differing subjective sensations of a 
morbid character, associated with imperfect audition, 
diminution of bone-conduction, and vertigo often re- 
sembling that occurring ab aiire Iceso. 

HEREDITARY SYPHILIS. 

Syphilis may be transmitted from progenitor to off- 
spring as a strictly inherited disease. The term " con- 
genital " has been somewhat loosely applied by different 
writers either to inherited syphilis or to syphilis acquired 
at birth of an infant and due to infection from recently 
developed chancres of the maternal passages. In these 
pages the term " hereditary syphilis " is employed to 
designate exclusively the disease acquired by inherit- 
ance. The term " congenital," as liable to beget con- 
fusion, should be dropped from the nomenclature. 

A vast amount of discussion has been elicited by 
questions concerning the etiology of inherited syphilis. 
It is sufficient here merely to state that, for most cases, 
the fact of a syphilitic child points to inheritance from 
the mother. When the father is without question 
syphilitic, and children are born syphilitic, the mother, 
free from all evidences of the disease, has probably 
been infected. She betrays no evidences of this infection 



206 SYPHILIS AND THE VENEREAL DISEASES. 

either because at the date of observation syphilitic 
symptoms previously exhibited have disappeared, or 
because the proofs of her morbid state are to be sought 
exclusively in the fruit of her several pregnancies and 
in the striking fact that she is incapable of infection by 
her syphilitic offspring, according to the law of Colles, 
given on page 207. 

The apparently healthy mothers who give a history 
of a succession of abortions, miscarriages, and birth of 
infected children due to syphilis can to-day be grouped 
in a class well recognized by every expert. It can- 
not always be determined whether such women have 
been infected with syphilis directly from the husband, 
as has been claimed, or indirectly from the syphilitic 
contents of the uterus. These mothers may even be in 
generally poor health, anaemic, weak, and debilitated, or 
they may exhibit every evidence of sound health, being 
vigorous, brawny, red-cheeked, and with all their func- 
tions duly performed. In these instances, without ques- 
tion, the syphilitic symptoms consist of the fruit of a 
series of conceptions. Just as syphilis of the healthy 
adult in some of its stages limits itself definitely to a 
persistent or recurrent patch of tubercles on the buttock 
or on a hand, so in these apparently healthy women the 
disease limits itself absolutely to the symptoms exhibited 
— a diseased ovum, foetus, or infant, frequently several 
of each in a single history. When, however, the mother 
is without question exempt from the suspicion of syphi- 
lis, and the father is as surely syphilitic, the child in- 
variably escapes. Cases of such absolute exemption on 
the part of the mother are those where, the father being 
assuredly the subject of the disease, the mother has 
never had an abortion, a miscarriage, a diseased child, 



HEREDITARY SYPHILIS. 20/ 

or any other symptom of the disease, and exhibits all 
the evidences of sound health. 

Colles's law, first formulated in 1837 ^7 Abraham 
Colles of Dublin, embodies the well-known fact that, 
although it is admitted that the mouth of a syphilitic 
infant is infectious for every other person, no mother of 
such a child was ever given syphilis by her own off- 
spring. No woman ever had a chancre of the nipple 
result from frequent contacts with the infectious secre- 
tions of her child's mouth. This law, the reported ex- 
ceptions to which are so few and so poorly established 
as to be worth nothing in the way of refutation, points 
conclusively to the fact above stated, that syphilis of 
the child always points to syphilis of the mother, either 
present or past, revealed by unquestioned symptoms 
or by a series of syphilitic conceptions betrayed as 
such by the occurrence of abortions, miscarriages, still- 
births, and infected offspring. 

The period of pregnancy beyond which the mother 
cannot, even if infected, transmit her disease to her un- 
born child is not fixed. It is probable that with different 
patients the period changes, the differences being due to 
the general health of the mother and to her aptitude or 
inaptitude for furnishing favorable ground for the action 
of the toxines of the disease. After the sixth month the 
child probably escapes ; but even so late as the seventh 
or eighth month, if the mother be infected, there is risk 
to the foetus. 

There have arisen in connection with this subject a 
few unimportant questions, the responses to which are 
by no means trustworthy. No man, in fact, can study the 
literature of the etiology of inherited syphilis, and have 
had experience of the disease in both public and private 



208 SYPHILIS AND THE VENEREAL DLSEASES. 

practice, without realizing the possibilities of error, in any 
given case, respecting the fact of parental disease and of 
error arising from the infective accidents common in the 
modern social life of large towns. Especially is this 
the case since the date of recognition of the practically 
innumerable opportunities for accidental infection af- 
forded by the medium of utensils, instruments, and the 
contacts of professional and domestic service. Thus, a 
child (born of a syphilitic woman) reported to be after 
birth the victim of an initial sclerosis, followed by signs 
of acquired disease, has almost certainly been infected by 
some accident after birth, and was free from inherited 
disease when born. The question also whether inherited 
syphilis can be transmitted to a third generation can for 
the immense majority of all cases be answered in the 
negative, the exceptions reported being not always 
thoroughly purged of the suspicion of accidental in- 
fection. No expert fails to observe at intervals cases 
of supposed " inherited disease " where a rigid and 
carefully conducted examination demonstrates that the 
disease was, as a matter of fact, acquired ; and the chil- 
dren of such parents, really suffering from acquired 
syphilis, and not from an inherited malady, would readily 
be assumed to represent a transmission of hereditary 
lues to a second generation. The question respecting 
acquisition of syphilis later in life by the subject of in- 
herited disease is to be answered with the same caution 
and reserve. Certain it is that syphilis in a few cases, 
after it is acquired, does not wholly protect its victim 
from a second attack of the same disease. We have 
already seen that these subjects of infection will occasion- 
ally, after exposure to initial scleroses, suffer from sin- 
gular and occasionally severe local ulcerations, simulat- 



HEREDITARY SYPHILIS. 209 

ing new initial scleroses, even at times with adenopathy 
of the neighboring glands, the prior infection, though 
preventing a new syphilis, being apparently insufficient 
to protect against local reinfection. The cases here con- 
sidered are not, of course, of the class where gum- 
matous deposits occur in the genital region of the in- 
fected at the site of merely local irritation. This reason- 
ing applies with special force to the rare cases reported 
in which a S3/philis derived from progenitors whose virus 
has been attenuated, presumably, in a score or more of 
years, loses at last, in the second generation, its power to 
furnish immunity against reinfection. 

Syphilis of the Placenta. — The placenta may exhibit 
signs of syphilis after the foetus has become the subject 
of unmistakable symptoms of the same disease. Many 
of the placental changes recorded by authors are un- 
doubtedly confused with those occurring in non-syphi- 
litic processes, and there is no basis for assuming of this 
viscus that it differs from others in that its lesions in the 
subject of syphilis are wholly due to the infectious dis- 
ease present. 

In some cases of undoubted syphilis of the offspring 

t ^e placenta has been found wholly free from morbid 

^\ nptoms, while at other times an endometritis placen- 

... occurs, in which dense nodules are found with a 

v" -^h fibrous capsule and a central mass composed 

of clusters of spindle-cells or of degenerating 

masses of a yellowish-white hue. With these 

..i' ta are masses representing transformed villi — 

■'iypt'in-rlastic, compressed, thickened, agglutinated, or 

>lly destroyed. Atheromatous and other meta- 

, ■ s involve the vessels of the umbilical cord, with 

resulti'^g ..'lickening of the intima, thrombosis, and even 

14 



2IO SYPHILIS AXD THE VENEREAL DISEASES. 

vascular obliteration. A result fatal to the contents of 
the uterus succeeds an involvement in these changes of 
the larger portion of the placenta. When handled, the 
placenta in well-marked cases is in parts firmly in- 
durated, is heavier than usual, and its lobulations dis- 
appear. In some cases circumscribed gummata may 
be detected by palpation of the mass, which, when in- 
cised, discloses grayish-yellow nodules with a fattily 
changed centre. Efforts to diagnosticate syphilis as 
derived from either the father or the mother by recogni- 
tion of changes in the placenta are apt to lead to un- 
trustworthy conclusions. 

It is a matter of im.portance to note that the liquor 
amnii of the woman bearing a syphilitic foetus is capable 
of communicating the disease to an accoucheur. 

Symptoms of Hereditary Syphilis. — One of the 
earliest and most frequent symptoms of syphilis in the 
product of conception is death of the ovum or foetus; and 
in a number of consecutive conceptions these symptoms 
often become conspicuous in a series of accidents of the 
same character. Thus, a woman infected by her hus- 
band soon after marriage may have a series of preg- 
nancies, covering a number of years, in which abortion ^ 
occur, first at an earlier and later at a more advancv d 
stage of gestation, these succeeded by one or more m\? ■ 
carriages, and the latter by the birth of a mature ch'id 
surviving but a few hours. Eventually a child r lay 
be born apparently healthy at birth, but devek pinjsf 
before the fourth month .symptoms of inherited sy ihwlis. 
Even after a series of such pregnancies there .nsty at 
last be brought into the world a healthy child w^ o riever 
exhibits signs of constitutional disease. The ^o^ltality 
in these cases falls between 60 and 90 per c it. 



HEREDITAR V S YPHILIS. 2 1 1 

About seven-eighths of diseased infants exhibit symp- 
toms of the inherited malady before the termination of 
the third month. Of the remaining eighth a certain 
proportion have actually exhibited symptoms either 
ignored or misunderstood. A small but unknown pro- 
portion betray evidences of transmitted disease at a date 
between the fourth month and the close of the first year 
of life. Cases were once reported of so-called "late" 
inherited syphilis in which the symptoms of the disease 
were supposed to be first displayed at or about the 
puberal epoch ; but there are few physicians who do not 
look with suspicion on such reports. It is believed, not 
without good reason, that the most of such patients really 
betrayed evidences of syphilis in infancy, but, as occurs 
so often in acquired cases, such symptoms were over- 
looked or were assigned to the indefinite category, often 
misinterpreted, of " children's disorders." Cases of bone 
disease in adults known to have syphilitic parents, the 
osseous lesions first appearing in the second generation 
after the twenty-fifth, the thirtieth, the fortieth, and even, 
as reported in one case, after the sixtieth year, are in 
general to be accepted with great reserve. 

Cutaneous Lesions of Hereditary Syphilis. — When 
miscarriages occur as a result of inherited disease, 
the foetus has often perished some days before its ex- 
pulsion, and its skin is then usually macerated and, in 
consequence of the feeble union between the epidermis 
and the corium, raised here and there in bullae, usually 
flaccid and filled with an ill-conditioned serum. This 
condition is often improperly termed *' syphilitic pem- 
phigus." In other cases there is born a viable child 
with a specific exanthem either affecting one region (for 
example, the palms and the soles) or extensively and 



212 SYPHILIS AND THE VENEREAL DISEASES. 

even generally evolved. In yet other cases the new- 
born infant may present at birth all the evidences of 
sound health, and at a later date, before the close of the 
third month, may develop insidiously the symptoms of 
cutaneous disease. Every practitioner is suspicious of 
an infant born into the world, even though living, con- 
siderably under the average weight, weazened, yellow- 
tinted, and snuffling, with the appearance of a " little 
old man " or a " little old woman," and exhibiting one 
or several " blisters " on the fingers or the toes. The 
appearance of premature senility in these weazened and 
speckled infants, with a flaccid skin which may be gath- 
ered between the fingers like that of some of the lower 
animals, with a circlet of papules about the anus or the 
mouth, with a feeble stridulous cry, and with obvious 
weakness, is often sufficient to enable one to establish a 
diagnosis at a glance. 

A macular syphilodenii in these infants has, in general, 
the shade observed in acquired cases, the difference 
being chiefly the larger size of the individual spots, their 
more pronounced shade, varying from a dull red to an 
empurpled hue, and their tendency to desquamate and 
secrete in regions of friction, pressure, and moisture. 
The color in some feeble and weazened children is a 
characteristically dirty brown, rarely imitated in any 
non-syphilitic infant. This exanthem may disappear or 
recur or be followed by others of a graver type. 

The papular syphiloderm of inherited disease is rarely 
as generalized, as dry, or constituted of as small-sized 
individual lesions as the corresponding eruption of 
acquired disease. In the infant, papules are apt to be 
grouped about portions of the face, of the trunk, or of 
the limbs; are often seated upon a hypersemic base; are 



HEREDITARY SYPHILIS. 213 

in general distinctly grouped; and usually tend to co- 
alesce and become flattened, scaling, or, in regions of 
moisture, friction, and pressure (as about the anus and 
the vulva), to secrete freely. In point of fact, the 
necessity of constantly applying napkins over the ano- 
genital region of infants, and the frequency with which 
(in the case of syphilitic infants especially) the accumu- 
lation of faeces and urine on these articles of clothing is 
permitted, make this region one in which the lesions of 
the disease are apt to be displayed not only often but 
in largest evolution. It is always incumbent upon the 
cautious practitioner to inspect the anal region of infants 
exhibiting an exanthem about which any suspicion is 
entertained. 

Often the circular outlines of groups of papules in 
hereditary disease is exceedingly distinct, the central 
portions of the enclosed area being apparently unaf- 
fected. These rings or portions of rings may be seen 
clustered about one angle of the mouth, where cracks 
may form in the angle itself, or about the buttock, or 
over the palmar and plantar regions. 

Bullous lesions in inherited syphilis are not rare, and 
commonly betoken grave conditions of the system. 
They may exist at the moment of birth of the dead or 
the living child, or they may afterward develop as pin- 
head- to bean-sized and larger elevations of the epider- 
mis, filled, as a rule, with an ill-conditioned sero-pus or 
blood, having an inflammatory areola of dirty hue, and 
followed, after bursting and release of their contents, with 
blackish, greenish, and dirty-yellowish crusts. The 
palms and the soles, as also the digits of either hands 
or feet or both, may be the seat of these lesions, which 
may be followed by ill-conditioned ulcers. 



214 SYPHILIS AND THE VENEREAL DISEASES. 

Tubercles in inherited syphilis are usually multiple, 
deeply seated, and grouped, and they soon undergo 
degeneration. They often precede a condition in which 
form greenish-black sloughs, ulcers spreading deeply 
beneath. 

The forms of hcniorrJiagic syphilis described by authors 
include those in which severe umbilical hemorrhage 
occurs at or soon after birth, as also the cases in which 
bullous lesions become filled with blood, and those in 
which distinctly purpuric blotches spread sparsely or in 
large numbers over the integument. Some of these 
forms are undoubtedly not to be distinguished from 
haemophilia. 

The mticoiis vievibranes.m inherited as in acquired dis- 
ease, display bullous lesions, papules, tubercles, mucous 
patches, and even pustules. These several lesions in 
the profound dyscrasic state of weakly infants often 
rapidly degenerate into the most formidable ulcerations. 
By the presence of the secretions which are abundantly 
furnished in children, and desiccated readily by the cur- 
rents of air when the mouth is kept open habitually in 
the weak state of the child, the nares become blocked 
by an obstructive rhinitis, and the respiratory tract, par- 
ticularly of the larynx and of the trachea, is greatly en- 
cumbered. In this way arise the catarrhal symptoms — 
the peculiar " snuffles " of the syphilitic baby, its feeble 
and stridulous voice, the necessity of abandoning its 
grasp of the mother's nipple in order to breathe and to 
cry, — all marked characteristics of the disease in the 
new-born of the second generation. In advanced stages 
of involvement of the mucous surfaces the respiration 
becomes seriously impeded when there is unusual effort 
of any sort. When no special effort is made the child 



HEREDITAR Y S YPHILIS. 2 1 5 

lies listless in its mother's lap or arms, with pinched, sal- 
low features, its limbs flaccid and extended, and its ex- 
pression indescribably apathetic. At any time during 
the evolution of the symptoms here described an inter- 
current disorder (pneumonia of a low grade, an incoerci- 
ble diarrhoea, or a progressive marasmus) may bring on 
a fatal termination. The respiratory tract as far as the 
bronchi is much more readily involved in infantile than 
in acquired disease. 

The 7iails are involved in inherited disease both pri- 
marily and as a result of changes in the nail-fold, the 
matrix, or the bed. When primarily affected, any one 
of the lesions named above may appear and be followed 
by suppuration or ulceration, with shedding of the nail ; 
or the nail-plate may become dry, fissured, " worm- 
eaten," yellowish, crumbling, or in various degrees dis- 
torted, or it may suddenly be shed. 

The liairs in hereditary syphilis fall as in acquired 
disease, and this either before or after the birth of the 
infant. The loss may be partial or complete, and if 
partial may consist either of a thinning of the hairs in 
one recrion or of their removal en masse from definite 

o 

areas, circular, irregularly shaped, or in ribbon-like 
stripes. Usually the scalp is chiefly involved. 

The lymphatic vessels and glands exhibit changes due 
to inherited syphilis, notably by signs of engorgement, 
infiltration, and enlargement. The thymus is chiefly in- 
volved, but all the thoracic and abdominal glands may 
be implicated, including the parotid, the inguinal, and 
the axillary. 

The genital organs of both sexes may be attacked, the 
penis and the testicles of male infants (epididymis and 
testes) especially. In both sexes these organs may be 



2l6 SYPHILIS AND THE VENEREAL DISEASES. 



undeveloped, approaching in appearance the rudiment- 
ary type. 

The bones are more often involved in inherited than in 
acquired disease, the percentage of cases in which there 
is osseous change being over one-third. Many lesions 
of bone in children are unrecognized in consequence of 
the greater gravity of other symptoms present. The 
bones most frequently involved are the tibia, the ulna, 
the radius, and other bones of the extremities, the clavi- 
cles, and the bones composing the skull. The special 
lesions recognized are those described under the title of 

osseous lesions in ac- 
quired disease — namely, 
circumscribed gummata 
of outer plates and med- 
ullary canal, periostitis, 
and rarefying or forma- 
tive osteitis. Caries, ne- 
crosis, and the induction 
of both ulceration and 
osteophytic growths are 
not rare. These growths 
at times induce prema- 
ture closure of the fon- 
tanelles, resulting event- 
ually in microcephalic 
idiocy. These lesions, 
with the others named, 
when affecting bones in 
contact with important 
nervous cells or trunks, 
may induce all the phenomena of nervous syphilis, 
cephalalgia with nocturnal distress, paralytic symptoms, 




Fig. io. — Sabre-blade deformity of the 
tibise in hereditary syphilis. 



HEREDITARY SYPHILIS. 21/ 

epileptiform seizures, remediless surdity, and even im- 
becilit}'. 

The hyperostoses of the tibia (occasionally of both 
tibiae) produce at times a highly characteristic change in 
the contour of the legs. Marked anterior convexity 
results from an osteophytic growth along the crest, 
which has been termed by the French " sabre-blade de- 
formity" {lame de sabre) (Fig. lo). Frightful ravages 
occur also in the face, which may be converted into a 
wide area of destructive processes, the orbits half dis- 
tended with shrunken and sightless globes, the upper lip 
and the maxilla absent and furnishing the orifice of a 
chasm composed of the oral and nasal cavities studded 
with partly healed ulcers and fungous masses. 

The pseudo-paralysis of hereditary syphilis produces 
helplessness of a single member, due to separation of the 
epiphysis from the diaphysis of one of the long bones. 
When unrelieved for some time, the ultimate sequence 
may be atroph}^ of the muscles. This epiphyseal sepa- 
ration is usually induced by an osteo-myelitis — a condi- 
tion to be distinguished from that in which pseudo- 
ankylosis results from decubitus and posture-fixation in 
consequence of grave disease of other organs (for ex- 
ample, a lower extremity after long-continued ulceration 
of a gummatous tumor seated upon the adductor muscles 
of the thigh). 

Fractures in bone-syphilis of infants are not rare, but 
it is to be noted that in these cases repair commonly 
ensues as after fractures of the non-infected. 

Care should be observed, in the diagnosis of bone 
disease in hereditary syphilis, not to confound the lesions 
with those of osteomalacia or rickets, though it has been 
held that the symptoms of the latter are actually those 



k 



2l8 SYPHILIS AND THE VENEREAL DISEASES. 

of syphilis in the second generation. In rickets the 
bones are thinned, and not enlarged as in syphilis, and 
do not show the characteristic bosses or nodes visible 
in the skulls of many syphilitic infants. In rickets 
also the fontanelles are open, rather than closed pre- 
maturely by osteophytic growths ; the ribs are beset 
with ridges or nodes ; and the characteristic symptoms 
of the " knock-knee " and the protuberant belly are in 
every well-marked case conspicuous. In tubercular and 
other bone diseases of children there is, of course, 
exclusion of a history of syphilis in the progenitors, and 
of abortions and still-born children ; absence of other 
symptoms of syphilis ; a frequent limitation of the dis- 
ease to a single bone ; a tendency to the production of 
what is known as " cold abscess ;" abnormal thermal 
variations ; and, in the instance of tuberculosis, the pos- 
sibility of the discovery of tubercle bacilli. 

The dactylitis syphilitica of inherited syphilis scarcely 
differs from the symptoms of the same affection in 
acquired disease. One or several digits may be in- 
volved, the changes occurring in the early years of life. 
The fall of the distal phalanges upon the head of the 
corresponding metacarpal bone is usually highly sig- 
nificant when the proximal phalanx has been removed 
by absorption of its mass ; and the same is true of the 
oval tumors representing symmetrical involvement of all 
tissues surrounding a single phalanx, with fistulous 
sinuses leading to carious bone or cartilage concerned in 
an adjacent joint. In some cases the disease begins in 
the joint, with symptoms of subacute inflammation and 
exudation ; or the capsules, the tendinous sheaths, or 
the fibrous tissues may be involved, with the result of 
producing a synovitis of more insidious development. 



HEREDITARY SYPHILIS: 219 

In yet other cases the synovial membrane thickens 
and becomes the seat of overgrowths simultaneously 
with the thickening of the periarticular tissues. 

The nasal passages in inherited syphilis are chiefly 
affected with a variety of syphilitic rhinitis of purulent 
type, whose secretion, flowing over the lips, produces 





t _ ^^^^B 


■ 


^Vr 

^K^ 


-J^ 




W^<^ 


IPV 


fl 




^^^^^l^^^-{^^3k 


^Bk' "V/ ^^^^I 



Fig. II. — Hutchinson's teeth with osteo-periostitis and ulceration in inherited syphilis. 

by excoriation a characteristic dermatitis. Infiltra- 
tion of the mucous membrane lining the passage 
results, as also the obvious condition of " snuffles " 
already described. Sucking, respiration, and phonation 
are seriously impeded, and in late cases destructive 
effects upon the nasal and palatine bones may result. 



220 SYPHILIS AND THE VENEREAL DISEASES. 

The teetli in inherited syphihs are characteristically 
altered, being, when affected, retarded in evolution and 
imperfectly formed in the first dentition, and in the 
second distorted. Hutchinson in 1863 described changes 
in the permanent teeth that are not invariably, but gener- 
ally, found in syphilitic children reaching an age when 
the eruption of these teeth has been accomplished. The 
central upper incisors are chiefly involved, showing 
semilunar notches at the free or cutting edge, these 
teeth and others being often also pegged and changed 
in color to a yellowish hue (Fig. 1 1). Often minute pits 
can be detected in the enamel. These changes in the 
teeth, when associated with parenchymatous keratitis and 
the scars of former fissures at the angles of the mouth, 
are justly regarded by most physicians as pathogno- 
monic of inherited syphilis. 

The //^^;7//;r in hereditary syphilis may be the seat of 
mucous patches, erythematous blotches, or circum- 
scribed or diffuse infiltration. In exceptional cases 
verrucous vegetations form on the membrane ; the 
tonsils become vohmiinous ; ulceration of a superficial 
or a deep character may involve the submucous tissue ; 
or grave forms of stomatitis supervene, the membrane 
of the mouth exhibiting on exposure an ashen look. 
In patients of unusual debility hemorrhagic effusions 
occur. When the bones are attacked the hard palate 
may be involved, and, especially in inherited disease 
which has existed for some years, the oral and nasal 
cavities are fused by ulcerative and destructive processes 
into a single formidable chasm. Often the anterior por- 
tion of the nares, the upper lip, and the hard palate in 
front are merged in a common ulcerative fossa. These 
destructive results may originate in either one of the 



HEREDITARY SYPHILIS. 221 

two cavities, or in a grave gummatous involvement of 
the skin of the face followed by severe sloughing. 

The larynx, the trachea, and the bronchi may each be 
the seat of changes in inherited syphilis — infiltrations, 
circumscribed or diffuse, of the mucous or submucous 
tissues, followed or not by ulceration which may destroy 
the perichondrium or the cartilages. Here, as from other 
of the mucous surfaces affected in the disease, polypiformx 
and verrucous excrescences may spring from the mem- 
brane, and when situated in the larynx or the trachea 
produce severe dyspnoea and disorders of phonation. 
The ulcers of this region differ but little from those 
exhibited in acquired disease, being single or multiple, 
and situated centrally or on one or both sides of the 
larynx. The lesions of the trachea and the bronchi are 
rare and are of the same general character as those of 
the larynx. 

Attention has already been directed to the clinical 
symptoms dependent upon the changes here noted — 
namely, the husky or stridulous cry of the infant, often 
progressively hoarse until wellnigh complete aphonia 
results. The impairment of respiration, the frequent 
raucous cough, evidently productive of pain and taxing 
to the utmost the strength of many of these feeble, 
wailing infants, and the symptoms of dyspnoea, laryngeal 
spasm, and oedema of the glottis, are all significant. 

The htngs, when involved in inherited disease, exhibit 
changes in the line of either definitely formed gum- 
matous deposits or of " syphilitic pneumonia," the pro- 
cess then diffusely involving a large area of a single lobe 
or an entire lobe of one lung. The tissue is firm on sec- 
tion, sinks in water, is grayish in hue, and its alveoli are 
distended with swollen epithelium. Gummata of the 



222 SYPHILIS AND THE VENEREAL DISEASES. 

lungs are commonly miliary or lenticular in size, with 
central necrosis proceeding to fatty degeneration. These 
nodules have a grayish hue, and they are set in dense 
pulmonary infiltrations of inflammatory type. 

Syphilis of the oesophagus, the stomachy mid the intes- 
tinal tract is rather less rare than in acquired disease. 
In the intestines, especially, both definitely circum- 
scribed and diffuse gummatous infiltrations have been 
recognized, large and single or numerous small 
ulcers resulting. The peritoneum may in some cases 
participate in the inflammatory processes present. 
Whether the symptoms be recognized before death (by 
palpation of the abdominal walls or by a catarrhal con- 
dition of the bowel) or post-mortem, agglutination of 
the intestinal coils usually has occurred. 

The liver, when involved in inherited syphilis, may be 
the seat of circumscribed or diffuse gummata set in a 
dense hepatic mass, with obliteration of many, if not all, 
of the hepatic capillaries as a result of arteritis. There is 
commonly an odd-looking marbling or mottling of the 
hepatic surface. At times the portal vein exhibits enor- 
mous overgrowth of its connective tissue, choking its 
lumen ; at other times the liver-cells seem to be com- 
pressed by a small-celled infiltrate squeezing the paren- 
chyma. The gummata may be miliary in size or as large 
as filberts, both types having a characteristic grayish 
hue. This color is not to be confounded with that of 
the minute, semi-transparent granules supposed to rep- 
resent unaltered hepatic tissue. The surface of the 
organ is either perfectly smooth or dotted with puncti- 
form depressions, probable sites of localized hepatitis 
induced by the presence of gummata. A portion only 
or the whole of the liver may be affected, and the 



HEREDITARY SYPHILIS. 223 

changes in its volume, the degree of its scirrhous hard- 
ness, and its shade of color are due to differences in the 
stages of its involvement. 

The spleen is enlarged in from one-fifth to one-fourth 
of all cases of inherited disease, being in cases many 
times more voluminous than in health. There is com- 
monly a hyperplasia productive of a densely indurated 
mass, or circumscribed or diffuse gummata, these 
changes often coexisting with hepatic lesions of the 
disease. 

The rectum and the anus of infants affected with hered- 
itary syphilis are involved as in acquired disease, stric- 
ture of the rectum, however, rarely resulting. In infants 
not properly cleansed the production of condylomata, 
moist papules, and secreting tubercles about the anus 
and the vulva is greatly favored by the accumulation of 
faeces and urine on the napkins of the child. 

The kidneys^ when involved in syphilis of the second 
generation, may present evidences of interstitial inflam- 
mation, lardaceous degeneration, and alterations in the 
epithelium of the convoluted tubes not characteristic of 
this special malady. 

The nervous system in hereditary syphilis may suffer 
from changes in the brain, the cord, or the peripheral 
nerves, in their membranous or osseous envelopes, and 
in the tissues with which the latter are in intimate 
relation. 

The cranial bones are in cases characteristically changed 
by circumscribed or diffuse atrophic osteitis of gelatini- 
form type (the bones becoming softened to the con- 
sistency of jelly, or presenting a " worm-eaten " appear- 
ance), or by osteophytic osteitis, as a consequence of 
which bosses (nodes, exostoses, hyperostoses) form in 



224 SYPHILIS AND THE VENEREAL DISEASES. 

special regions, producing in the skull of the infant a 
highly characteristic deformity. In one type the cranial 
bones are merely symmetrically changed and fixed or 
floating; in another they bulge as in hydrocephalus; 
in another the forehead pushes forward above, producing 
the effect of massiveness ; in another each frontal pro- 
tuberance is symmetrically studded with circumscribed 
rounded bosses or prominences ; in yet another the brow 
edges forward in the mesian line, producing a keel-like 
aspect. Microcephalus may result either from formative 
osteitis making a cruciform or other shaped bridge over 
the fontanelles, thus interfering with the development of 
the skull, or from simple failure of evolution, the stunting 
being dependent upon general rather than upon local 
causes. Whether or not this condition and that of 
rachitis be due in some cases to syphilis indirectly, and 
in others to different morbid states not well understood, 
is not fully determined. The general belief among 
experts is that these and other evidences of failure of 
development are symptoms of cachectic states which 
may be induced by syphilis and other affections. 

Subacute and chronic types of leptomeningitis, in 
which the dura mater or the pia mater may be involved 
primarily or secondarily, are not rare among syphilitic 
children ; they require to be compared closely with the 
other signs of inherited lues, in order to be differentiated 
from tubercular affections of the meninges. Hemor- 
rhages are occasional complications of these attacks, 
provoked by the presence of gummata in the cranial 
bones or in the pericranium. The cerebrum, the cere- 
bellum, the pons, and the medulla may each be the 
seat of changes produced by any of the forms of ar- 
teritis studied in connection with the brain-syphilis of 



HEREDITARY SYRHIL/S. 22 5 

acquired disease, the ultimate results being seen in the 
formation of aneurysmal pouches, irregular distribution 
of blood to the nervous tissue, thrombosis, embolism, 
and hemorrhages. Gummata, as in acquired disease, 
may develop in the nervous substance ; and encephalitis, 
cerebral sclerosis, ependymitis, ecchymosis, and softening 
may ultimately result. 

The clinical symptoms springing from these organic 
changes, slight or severe, vary from feeble-mindedness 
and mental states suggestive of complete idiocy to in- 
sanity and epileptiform attacks, though the latter are 
rarer in congenital than in acquired disease. Single or 
multiple paralyses of centric origin, hemiplegias and 
paraplegias, with the usual accompaniment of severe, 
continued, or recurrent headache, are common results 
of these intracranial lesions. Recurrence of nervous 
phenomena of a severe grade, a distorted cranium, and 
an idiotic mental state point to inherited syphilis of the 
child even in the absence of any history of infection of 
one or both parents. The evidences of inherited disease, 
in the rare instances in which the cord and the periph- 
eral nerves are involved, are obscure. Cases are rare in 
which opportunity is offered for their investigation. The 
oculo-motor paralyses of acquired disease are here oc- 
casionally noted. 

The eye in inherited syphilis is subject to many of the 
disorders observed in acquired disease. Parenchyma- 
tous keratitis (chronic interstitial keratitis) is often found 
associated with the teeth described by Hutchinson, 
already noted, the combination of the two affections 
practically establishing a diagnosis of inherited syphilis. 
The cornea in these cases first becomes cloudy in punc- 
tate lesions recognized on close inspection as seated in 

15 



226 SYPHILIS AND THE VENEREAL DISEASES. 

the parenchymatous tissue. Gradually, in the course of 
a few weeks or less, the entire cornea presents a cha- 
racteristic " ground-glass " appearance, in consequence 
of the multiplication and fusion of these points of opacity, 
with a pericorneal zone of injection, one or both eyes 
being attacked, and the two organs simultaneously or 
successively. The issue is either a gradual clearing up 
of the opaque condition, which at its fullest evolution 
practically occludes the entrance of light, or a more or 
less intense injection and vascularization of the corneal 
surface. Iritis is rarer in inherited than in acquired 
disease, but it occurs in one or both eyes and before or 
after birth, plastic effusions in the worst cases gluing 
the iris to the capsule of the lens. Choroiditis and 
retinitis also occur in inherited disease, with the iris 
and the pupil unchanged, and dust-like particles in the 
vitreous humor originating in patches of infiltration of 
the choroid. Retinitis and optic neuritis in children 
have rarely been observed. 

TJie Ear. — The persistent deafness of many subjects of 
inherited syphilis arise from changes in the tympanum 
and the middle ear. The lesions correspond, for the most 
part, with those heretofore described in connection with 
acquired syphilis. The deafness is due, in general, to a 
labyrinthitis characterized by a cellular infiltration of the 
membranous labyrinth and to a serous effusion into the 
endolymph, with eventual increase of connective tissue 
which may later undergo a species of cicatricial con- 
tracture. Prominent subjective symptoms are the usual 
morbid aberrations of audition (roaring, blowing, ring- 
ing, singing, and other sensations), more or less rapidly 
changing to absolute surdity. There may be, as in adults, 
coincident vertigo, cephalalgia, and febrile phenomena. 



TREATMENT OF SYPHILIS. 22/ 



TREATMENT OF SYPHILIS. 

No treatment of syphilis may be regarded as worth 
the name that excludes early and persistent attention 
to the general health of the patient. This hygienic care, 
as contrasted with the medicinal measures employed, by 
far outweighs the latter in importance, and practically 
decides for many cases the question of the gravity of 
the issue or the reverse. The worst errors committed 
in the management of syphilis are due to trusting 
exclusively in the efficacy of drugs for relief of the 
disease. 

Hygienic Considerations. — The patient affected with 
syphilis should always be given a sufficiently ample 
dietary, the food to be simple and digestible. For the 
gouty the food should not be that allowed the cachectic 
and the anaemic. Allowance being made for these ex- 
tremes, it may be said in general that the syphilitic 
patient requires an ample supply of nutritious and 
digestible food, seeing that, even in the case of the sub- 
ject of the disease who is at the outset well fed and well 
nourished, it cannot always be known when the toxines 
of his malady so change the systemic condition that at 
a date not far distant the picture may be altered for 
the worse. 

Alcoholic beverages may be used in the treatment of 
syphilis with wise discretion. In the case of the en- 
feebled the weaker stimulants, such as white wines, beer, 
ale, porter, and the malt extracts, m^ay often be employed 
with great advantage to the patient; while the use of 
such articles as spirits, champagne, and Burgundy or 
Port, if drunk freely and in persons of a gouty state, 



228 SYPHILIS AND THE VENEREAL DISEASES. 

may be positively injurious, and may actually prolong 
the period during which the malady requires treatment. 
Here, as in so many questions arising in medicine, the 
judgment of the practitioner, instead of a fixed rule, 
must finally decide. 

Bathing is of importance in all cases. The very hot 
baths largely employed in the various health-resorts 
and springs of all countries are without question often 
harmful, and are to be ordered for the average patient 
only after due consideration. The skin of the body, 
however, should, when practicable, be sponged daily, 
exception being made for the menstrual period in women. 
Persons of a delicate constitution should simply moisten 
a handful of warmed salt with hot water and rub this 
over the skin-surface, using afterward a coarse towel or a 
flesh-brush to ensure a vivid reaction. For stronger 
patients, especially vigorous young men, daily cold 
sponging of the entire body, from the neck to the feet, 
Avith water to which salt has been added in the strength 
of one-quarter of a pound to the gallon is of high value. 
Hot baths and hot applications of all sorts for a skin 
liable to exhibit a syphilitic exanthem are decidedly 
objectionable. By keeping the surface well polished and 
in a high degree of tone the liability to pustular and 
other syphilodermata is practically set aside. 

The use of tobacco, either by smoking, by chewing, or 
as snuff, is harmful to the mouth and to the nares of 
syphilitic subjects, inviting as it does the occurrence in 
these parts of mucous patches and other lesions. It is 
decidedly the wisest course in every case to interdict 
absolutely these practices from first to last. In the same 
connection it is well to remember that male patients 
deprived of tobacco are apt to hold cigars or a tooth- 



I 



TREATMENT OE SYPHILIS. 229 

pick in the mouth, or even to chew gum for hours at a 
time, in order to allay the craving for tobacco. Each 
of these practices is harmful, and has repeatedly pro- 
duced the most painful and persistent fissures of the 
commissures of the lips, and even obstinate ulcers. 

It is well to bear in mind the measures recognized as 
efficient in the management of other disorders producing 
deterioration of the general health. Diversion of the 
mind, abstraction from the fatigue and anxiety of busi- 
ness and professional work, foreign and domestic travel, 
the invigorating influences of a sea-voyage or a sojourn 
in the mountains, out-door living and open-air amuse- 
ments, — all these have a distinct value in appropriate 
cases. 

The recently infected subjects of syphilis, and often 
those who have suffered longer, should in general ex- 
clude the possibility of a determination of the activities 
of the disease to any one region of the body by setting 
aside, so far as practicable, all local sources of irritation. 
Carious teeth should be removed or their cavities be 
stopped ; projecting edges of teeth in contact with the 
tongue should be removed by the dentist's file ; a weak 
eye (particularly if employed out of doors with snow 
on the ground) should be protected ; and a ponderous 
varicocele, a scrotal hernia, or a hemorrhoidal tumor 
should receive proper attention. 

Time for beginning the Systemic Treatment of 
Syphilis. — It has already been shown that treatment of 
the chancre, whether by internal or external medication, 
is not the treatment of the disease which follows. At- 
tempts to abort syphilis at the onset are usually as 
futile as similar efforts to jugulate the other maladies 
with which man may be affected. In any case in which, 



230 SYPHILIS AND THE VENEREAL DISEASES. 

whether from the local phenomena (initial sclerosis, 
syphilitic bubo) or from special conditions aside from the 
local symptoms, it is deemed prudent to begin the treat- 
ment of syphilis before the establishment of an absolute 
certainty respecting its diagnosis, general treatment may 
properly be instituted, with the distinct understanding 
that such treatment will neither assuredly abort nor miti- 
gate the symptoms which are to be expected later. 
The reverse is also true — namely, that delay in insti- 
tuting systemic treatment of syphilis until the fullest 
recognition of the disease has been established in no 
wise jeopards the future of the patient nor his amena- 
bility to the later management of his malady. It has 
already been set forth in these pages that in a sound 
young patient free from signs of other trouble, infected 
with syphilis and properly treated thereafter, there would 
probably result but a single exanthem (the macular 
syphiloderm), upon the disappearance of which, when 
all the other hygienic and therapeutic conditions were 
absolutely fulfilled, no other symptom of the disease 
should follow. However impossible the attainment of 
such an ideal, its practical realization in selected cases 
points with clearness to the clinical fact that some ex- 
pression of the disease, early or late, is in the nature of 
the affection to be expected. After such complete ex- 
pression subsequent processes may be in the line of in- 
volution rather than of evolution. A very abundant 
macular syphiloderm not uncommonly disposes of the 
major part of all symptoms of systemic syphilis, and if 
this first exanthem be aborted, suppressed, or greatly in- 
fluenced by energetic treatment (which is certainly in 
some cases effected), the future of the patient is to a 
degree clouded. One early vivid and generalized efflo- 



TREATMENT OF SYPHILIS. 23 I 

rescence is an augury for good in an otherwise healthy 
subject. No treatment is superior in results to that 
directed with energy, system, and skill to a disease per- 
mitted a first frank evolution. 

The question, often formulated, " How long should 
the treatment of syphilis be continued ?" is best answered 
by stating the length of time during which the disease 
may persist. For some patients the disease and the 
treatment, as has already been seen, are alike ended long 
before other infected subjects have ceased to exhibit 
symptoms or to be treated for their relief. The treat- 
ment of rebellious syphilis in the unfavorable class of 
patients already described is, indeed, a tedious matter. 
For the average of subjects of the disease, healthy before 
infection and managed skilfully, it is not difficult to fix 
the duration of treatment. Most of such patients after 
two and one-half or three years have passed are prac- 
tically well. There are few sound persons thus cared 
for who may not suspend medication for weeks at a time 
after the conclusion of the second year. 

Systemic Treatment of Syphilis. — Medicinal treat- 
ment of syphilis is conducted by the aid of remedies 
both ingested and externally apphed. The former 
method is usually termed " internal," as distinguished 
from *' external " treatment. Both methods have been 
employed at different periods of time, either sepa- 
rately or in conjunction, with favorable results. These 
modes of medicinal treatment have been by some 
writers made to conform to certain systems ; as, for 
example, the so-called " tonic " method, in accord- 
ance with which a dose ascertained to be effective 
in the case of a single individual is continuously ad- 
ministered for a given length of time — a number of 



232 SYPHILIS AND THE VENEREAL DISEASES. 

consecutive months or years. Another system is the 
" interrupted," in accordance with which the patient is 
submitted to treatment of the disease by special medica- 
ments for a period of time, followed by a longer or 
shorter suspension of the remedy. Of the so-called 
" expectant " method of treating syphilis it is sufficient to 
say that few modern practitioners would dare to subject 
themselves to the charge of leaving a patient affected 
with the disease to such grave possibilities of danger- 
ous and even fatal results. In these pages the effort is 
made to set forth the treatment of syphilis on a rational 
basis, and wholly independent of any system whatever. 
Indeed, the skilful physician will ever free himself from 
the shackles of conventional rules, and will learn by 
experience to employ with advantage for his patients the 
method which in each single case is most clearly indi- 
cated and best adapted not merely to relieve for the 
time being the symptoms of the disease, but also to set 
aside its possibilities of damage in the remote future. 

Mercury. — In the face of vast opposition, and despite 
the fact that a large number of the lesions of syphilis 
have been attributed where they do not belong — to the 
assumed toxic effect of the metal which is of chief value 
in securing its relief — mercury to-day stands pre-eminent 
throughout the civilized world among drugs esteemed 
efficient both for the relief of the symptoms and for the 
radical cure of the disease. Like most agents that are 
both energetic and efficient, it is not a proper use, but 
an abuse, of its compounds that has brought upon it so 
much odium. 

It has long been regarded as axiomatic that mercury 
is chiefly valuable in the early, and the preparations of 
iodine in the later, periods of syphilis. In general this 



TREATMENT OF SYPHILIS. 233 

may be admitted to be true ; but the exceptions to the 
rule are so many that it may often be violated with the 
greatest possible advantage to the patient. 

The preparations of mercury administered by the 
mouth are, in the order of their value in the manage- 
ment of syphilis, the protoiodide, the bichloride, the 
biniodide, the tannate, blue pill, calomel, and the gray 
powder. Among American and French physicians the 
protoiodide has, and we think justly, a decided prefer- 
ence. 

On the supervention of the first symptoms of general 
syphilis, it is well, when the method of treatment by the 
mouth with digestion of drugs in the stomach is selected, 
to begin with a mercurial course by the aid of the pro- 
toiodide. This preparation is to be exhibited steadily 
until all obvious symptoms of the disease are removed, 
and afterward to an extent hereafter to be discussed. It 
is well to begin with an average dose of the metallic salt, 
and to increase or decrease this dose as indications may 
be furnished by the patient. Whether one or another 
article be selected for use, that medication only can be 
regarded as both efficient and desirable which is not 
intolerable to the system, under the influence of which 
the patient gains in weight, and which enables him to 
digest food with appetite and profit as regards nutrition. 
The following are practicable formulae for the pur- 
poses named : 

^. Hydrarg. iodid. virid., gr. xij ; 

Mas. ferri carb., 3J. — M. 

Ft. pil. No. Ix. 
Sig. One or two pills after each meal. 

From yiy to \ grain may thus be given after each meal 



234 SYPHILIS AND THE VENEREAL DISEASES. 

to a patient of adult years and average weight. The 
dose may be reduced or increased from day to day as 
required — diminished especially if there be looseness of 
the bowels, which to an extent is guarded against by 
the use of the ferruginous preparation named. For 
Vallet's mass the citrate of iron and quinine may be sub- 
stituted in doses of from i to 3 grains. 

When looseness of the bowels or colic is induced, the 
dose should be diminished or the habits of the patient 
with respect to food and drink should be controlled more 
carefully. The drinking of iced water, the eating of ice- 
cream, and the free use of fruits and of certain kinds of 
fish are often responsible for the excessive action of the 
bowels and for the pain induced by the drug. 

Instead of in pills, the combination given may be 
administered in capsules, the preparations for this 
purpose lately placed upon the market bemg readily 
digested and more soluble even in the fluids of the 
mouth than a coated pill which has been desiccated by 
time and by hot weather. The tablet triturates of the 
same metal are often used, but are open to the disadvan- 
tage of disintegrating when carried about in the pocket. 
The centigram granules of Messrs. Gamier & Lamoureux, 
which have long been esteemed highly in America 
and abroad in the management of the disease, are cer- 
tainly of great value, as the pill is elegantly made and 
is efficiently preservative of its contents. Upon com- 
parison with pills of the same dose of American manu- 
facture, made, for the most part, by skilful precipitation 
of the green iodide, the latter will in general be found 
to be superior. The French pill, however, has an actual 
advantage in the greater impurity of its constituents. 
For therapeutic purposes the dose of the yellow pro- 



TREATMENT OF SYPHILIS. 235 

toiodide in pill form, made by American chemists, should 
be nearly one-half that prepared by the French in the 
pill named. 

It is very rarely necessary to give an opiate in com- 
bination with mercurials in the treatment of syphilis, 
with a view to the introduction of a larger quantity of 
the metal into the system, or to relieve the diarrhoea 
produced by even small doses. This practice is a rem- 
nant of crude attempts at treatment instituted before the 
days of modern refinement in diagnosis and methods. 
It is to be regarded as a last resort for cases of extreme 
urgency and of very unusual irritability of the intestinal 
canal. Not merely may the combination beget the 
opium-habit in a person thus habituated to the drug 
(and frequently such habits have been acquired during 
treatment for syphilis), but harm is wrought by inter- 
ference with digestion. He who hopes to be brilliantly 
successful in managing syphilis will ever be jealous of 
any impairment of the digestive functions of his patient. 

" A chronic disease," as a great syphilographer has 
written, " requires a chronic remedy." Without adher- 
ing to any system, if it be found that, by steadily pursu- 
ing a mercurial course with the aid of the protoiodide, 
the symptoms of the disease disappear, and afterward 
the patient can still take the drug to advantage in doses 
that enable him to gain in weight or to hold it at nearly 
the maximum while attending to his or her usual voca- 
tion, meantime enjoying every sign of good health, a 
desirable and satisfactory end has been obtained. Cer- 
tainly no change, under these circumstances, is specially 
desired or required. It is well, when this fortunate issue 
is reached, to have the patient kept under more or less 
careful observation, the practitioner being at all times 



236 SYPHILIS AND THE VENEREAL DISEASES. 

ready to change the treatment, general or local, as 
may from day to day be suggested by any accidents 
that arise. 

At any time, however, when such a course seems 
desired, any one of the other preparations of the metal 
named may be substituted for the protoiodide. These 
preparations are the bichloride, in doses of from -^ to 
jlg- grain ; the biniodide, in doses of from -^ to ^-^ grain ; 
the tannate, in doses of from \ to I grain ; blue pill, in 
doses of from \ to i grain ; calomel, in doses of from 
j3^ to J grain ; and the gray powder, in doses of from i 
to 5 grains. Of these preparations, the biniodide, the 
tannate, blue pill, calomel, and hydrargyrum cum creta 
may be given in pill form ; the bichloride and the bin- 
iodide preferably in solution ; and calomel and the gray 
powder in the form of either powders or pills. It is to 
be remembered that in giving mercury it is not so 
miportant to discover how large a dose a patient may 
take with impunity at one time for the relief of his 
disease as to know how large a dose may be taken for 
long periods of time with the same end in view. It is 
rarely necessary to give more than 3 grains of the pro- 
toiodide by the mouth daily, nor more than \ ox \ grain 
of the sublimate, nor more of the other compounds 
named than can be regarded as an average rather than 
as a large dose. 

Upon the slightest evidence, however, even when any 
of these doses is being pushed to a proper maximum, 
that the disease or its symptoms is not properly yielding, 
there can be but little question that the proper course is 
to change the preparation selected. In syphilis the in- 
fective cells become later less amenable than at first to 
the antagonizing remedy, and each group of these cells 



i 



TREATMENT OF SYPHILIS. 237 

may become a focus from which, by the well-known 
processes of cell-multiplication and the production of 
toxines, the morbid process may be relighted to activity. 
Even the most trivial of lesions is to be combated 
energetically in this early stage ; and when resolution 
is not visibly progressing, not only is the remedy for 
internal use to be exchanged for another, but the topical 
treatment of any lesions present, as explained elsewhere, 
should either be modified or be more energetically and 
persistently pushed. 

The season for the happiest results from the manage- 
ment of syphilis is the first semester of its career. If 
any treatment may justly be described as "abortive," it 
is not that which seeks to jugulate the malady in its 
chancre-stage, but that which vigorously and efficiently 
obliterates all symptoms in the period of early evolu- 
tion. 

We beheve that when all progresses satisfactorily, the 
patient who secures complete immunity from symptoms 
of his disease in the first half year does better when no 
recognized antisyphilitic remedy is administered save 
mercury. Many of the best treated patients have never 
swallowed the compounds of iodine except in combina- 
tion with mercury. Other things being equal, he who 
has secured complete relief from syphilis without using 
the iodide of potassium has usually had either a mild or 
an exceedingly tractable form of the disease. 

Iron is administered with decided advantage to the 
great majority of all patients affected with syphilis, and 
it is well to order it in all cases where it is not contra- 
indicated. A convenient method is to prescribe a ferru- 
ginous tonic before the first and the last meal of each day, 
while the mercurial in pill or other form is taken after 



238 SYPHILIS AND THE VENEREAL DISEASES. 

each meal. Iron does its best work for most patients 
when ingested in a fluid form. The following is a con- 
venient formula : 

^. Ferri et quin. citrat., iss ; 

Limon. syrup., f^ij ; 

Aq. destilL, ad fgviij. — M. 

Sig. A teaspoonful in a wineglassful of water before the 

first and the last meal of the day. 
Iron may also be given in pill form or be combined with 
the bichloride in formulas of which the following may 
be taken as a sample : 

^. Hydrarg. chlorid. corros., gr. j-ij ; 

Ferri tinct. muriat., 

Acid muriat. dilut., aa. f^ij-iv; 

Syr. aurant. flor., f^ij ; 

Aq. dest, ad f^viij.— M. 

Sig. A teaspoonful in a wineglassful of water after each 
meal. 
When there is constipation, patients often find it of 
advantage to take some such formula as that given 
above, in proper doses after the first and tlie last meal of 
each day, and one or two pills or tablets of the pro- 
toiodide after the middle meal of the day. 

Inunction of mercury, or its systematic introduction 
by the skin, is one of the superior methods of treating 
syphilis. This practice has the excellent recommendation 
of sparing the stomach, which may then be reserved for 
food and drink, for tonics, and for whatever else in the 
way of adjuvant ingesta may at any time be required. The 
disadvantages of inunction are its relative uncleanliness 
and the need of more or less skill and time in its em- 
ployment. Few patients of the better class like to resort 



( 



TREATMENT OF SYPHILIS. 239 

to it for more than brief periods of time. There are few, 
however, who may not reap substantial benefits from 
smearing mercury even for short periods. It is wise to 
employ inunction, first, in all grave cases ; second, in all 
cases of emergency ; third, whenever the stomach proves 
intractable to drug-ingestion ; and fourth, whenever, even 
after generally favorable results from medication by the 
mouth, there are persistent lesions refusing to yield to 
general and local treatment. 

Mercurial ointment of the United States Pharma- 
copoeia, in 50 per cent, strength, still heads the list of 
mercurial preparations available for inunctions. It can- 
not be employed with equal advantage in combination 
with any drug. Mercurial plasters have in some cases 
a decidedly beneficial result as local applications ; and 
the 5, 10, and 20 per cent, oleates may also at times be 
used with advantage when there is no special urgency. 
No such reliance, however, can be placed upon them as 
upon the officinal blue ointment. 

When inunction is to be employed, the dose of the 
ointment should be varied according to the weight and 
the general condition of the patient, from i to 3 scruples 
being ordered to be well rubbed in at a single sitting. 
The smaller may often with advantage in any given case 
be increased to the larger dose named. The skin 
should usually have a preliminary cleansing in tepid 
water with soap, and often also a washing with borated 
water or with alcohol in order to ensure an aseptic state 
of the skin. Professional rubbers generally do better 
service than untrained servants or the subjects of the 
disease themselves ; but often the last named — especially 
women who are anxious not to betray to others the 
nature of their malady — learn to practise inunction with 



240 SYPHILIS AND THE VENEREAL DISEASES. 

excellent results. The ointment should be rubbed in 
until it has practically disappeared, with a gentle knead- 
ing motion of the hand, or, better, the two hands — 
practically the movement used in massage. The hand 
of an assistant, if such be employed, need not be pro- 
tected by gloves, seeing that a talc paste such as the 
modified Lassar may practically be made protective. 
The rubbings are preferably made at night, after which 
the patient retires to bed in clothing which is suffered 
to be soiled by contact with the salve. Diaphoresis 
induced by the drinking of hot fluids afterward (milk, 
spirits, etc.), recommended by some authors, is unneces- 
sary in order to secure the best results of the treatment. 
In hospitals it is customary to make the patients rub 
each other, usually on the back and simultaneously, the 
ward nurse having then to anoint but a single patient in 
the line. It is usual to order from one to four or five 
scores of rubbings, to be given on successive or alter- 
nate nights or at intervals of several days. Often it is 
desirable to give a course of twenty inunctions, after 
which the rubbing may be suspended while other treat- 
ment is pursued, the inunctions being renewed until the 
entire number advised is completed. When required, 
for special reasons, a useful method of inunction is to 
order the skin well rubbed with the salve, the part 
anointed being then covered by the customary clothing, 
which is worn afterward for a series of days. In this 
way stockings impregnated with the ointment may be 
kept in contact with the feet, while flannel undergar- 
ments may be employed with the same end in view. 
There are, however, few patients who relish the dirtiness 
and messiness of this practice, which is, in general, to 
be reserved for special cases, such as those where 



TREATMENT OF SYPHILIS. 2^\ 

neither the patient nor professional masseurs can do the 
work. 

When giving inunctions, the rule enunciated with 
respect to mercury by the mouth should not be forgot- 
ten. The ferruginous tonics are to be administered 
systematically while the patient is under the influence 
of the metal. He should also be given a generous diet 
and should have out-door air and exercise. 

The regions selected for inunction of the body are of 
some importance, as it is desirable that the ointment be 
rubbed into those parts where the skin is provided with 
glands through whose excretory orifices the metal may 
gain access to the economy. It is also desirable, in view 
of the readiness with which mercurial inunctions induce 
an artificial dermatitis in the region of application, that 
a new area of inunction be selected on successive days. 
This area secured, however, the refinements of authors 
respecting the selection of special regions of the body 
for inunction have little foundation in the way of attain- 
ing practical results. Inunctions of the thick sole of the 
foot are often as efficient as those on the sensitive and 
thinner integument of the groin or over the subclavian 
regions. 

We are in the habit of ordering inunctions first for 
regions of the upper segment of the body in succession, 
and later for those of the lower half successively, for 
reasons connected chiefly with the garment worn after 
the completion of the process. In this way, on one 
night the thighs and groins, on another the legs and 
soles, are anointed, and after this the drawers or pajamas 
worn are washed ; on other nights the surface of the 
belly and the breast, the arms and the axillae, the back, 
or the neck and the head may be smeared. It is to be 

16 



242 SYPHILIS AND THE VENEREAL DISEASES. 

borne in mind, further, that when the inunction is not 
employed with a view to acting directly upon lesions 
present upon the integument, the value of the inunction 
as regards the general system is as great when applied 
in one region as another ; and it is a matter of import- 
ance to encourage patients, especially those in private 
practice, to continue with their inunctions for the longest 
period advised. For the most part, they will consent to 
rubbings of the lower portions of the body for a longer 
time than to inunctions of the upper regions. The 
penis, scrotum, anus, face, ears, and the vulva and 
breasts of women are in general to be spared. 

There are i^^ patients, whether informed or not, who 
remain ignorant of the nature of the treatment when 
inunctions are employed. As a consequence, they are 
at times exceedingly anxious about " catching cold," 
using acids in their dietary, etc., for fear of toxic results. 
While due prudence must guide the practitioner in 
advising patients on these points, it is rare, with a prop- 
erly advised course of inunctions and with the subject 
of the disease kept under the observation of an intelli- 
gent physician (as should always be done throughout the 
treatment of syphilis), that accidents happen, even after 
imprudent behavior on the part of the patient. 

When inunction is practised with a view to direct 
medication of the skin (for example, in case of palmar 
or plantar syphilodermata), care should be observed to 
make the applications so far as practicable over all per- 
sistent lesions present. It is the skilful obliteration of 
all foci where infective cells, micro-organisms, or toxines 
may be present that preserves against the lighting up of 
morbid processes in these centres of undiminished 
activity. 



TREATMENT OF SYPHILIS. 243 

When a dermatitis is induced by the frictions inci- 
dental to the inunction process or as a consequence 
of the mercurial application, the results are rarely 
serious. Discontinuance of further rubbings over the 
region which thus expresses its resentment will usually 
suffice, in the course of a few days, to relieve the symp- 
toms. In any case where treatment really seems needed, 
the application of a simple dusting-powder or of Lassar 
paste usually suffices to allay the itching and the local 
irritation. 

The modified Lassar paste is made by adding 2 to 4 
drachms each of talc and zinc oxide to ^ ounce of 
white vaseline, with from 5 to 20 grains of salicylic 
acid, the whole rubbed together until a smooth and 
impalpable paste results. It is more or less adherent to 
the skin, and, apart from the value of its medicinal con- 
stituents, has the advantage of protecting the surface to 
which it is applied. 

Fumigation. — The treatment of syphilis by the aid of 
the mercurial vapor-bath is both efficient and speedy. 
In any emergency it is capable of producing more rapid 
effects in a given time than any of the methods thus far 
described. In the large cities it is customary to send 
patients to bath establishments, where, by the aid of 
somewhat elaborate apparatus, aided by steam-supply 
and by special devices for exposure of the head without 
necessitating inhalation of the vapor, the patient is fumi- 
gated by the aid of trained assistants. However, with 
the Lee or the Maury apparatus, and an extemporized 
chamber, constructed either of bed-blankets or of ticking, 
which can be fashioned by any seamstress so as to en- 
compass the patient's body as high as the neck, the same 
results can be attained with trifling trouble and expense. 



244 SYPHILIS AND THE VENEREAL DISEASES. 

Indeed, without any special apparatus, an ordinary tin- 
smith can construct a pan for holding the metallic salt 
to be vaporized over a spirit-lamp, which, with a kettle 
of boiling hot water by its side, furnishes all required 
accessories. 

Calomel or cinnabar is usually selected for vaporiza- 
tion, and often the two in combination — about one-fourth 
more of the latter than of the former when the two are 
commingled. From i to 3 scruples of the single salt or 
of the two may be employed at a sitting, the quantity 
being estimated not merely from the condition of the 
patient but from the size of the chamber to which steam 
is admitted, since much more may be used in the large 
receptacles of the bath-houses than in the extemporized 
blanket or ticking tent which may be employed by a 
country physician at the bedside of his patient. The 
exposure should last for about half an hour — less if the 
patient becomes faint during the steaming. As a rule, 
the subject of the disease should be fasting at the bath- 
hour, which is preferably that preceding his or her ac- 
customed hour of sleep. As it is by no means rare for 
the subject to become faint, it is well to have a stimulant 
at hand, and, even in sending patients to the bath- 
houses, to advise the carrying with them of a small flask 
of sherry or brandy. A bath every third or even every 
second day is sufficient save in cases of emergency — 
as when there has been ignorance of the nature of the 
disorder before the first consultation, and the patient has 
a highly disfiguring facial exanthem forbidding his or 
her customary association with family or friends. In such 
event, and for brief periods of time, a bath may be taken 
daily ; but in these cases, as well as in the others, it is 
needful to remember that the patient is often debilitated 



TREATMENT OF SYPHILIS. 245 

by the steaming, even when vastly improving in the mat- 
ter of the removal of the lesions which place his case in 
the emergency class. These emergency cases, further- 
more, are often those of patients suffering from febrile 
reactionary symptoms (syphilitic fever), and the need of 
ferruginous tonics, of quinine in ample doses, and even 
of a generous glass of wine with the dinner, should not 
be forgotten. Local mercurial fumigation by means of 
the apparatus sold in the shops is of value in many 
cases for direct application of the vapor both to the skin 
and the mucous cavities. We have, however, practically 
limited our use of this method to the nasal passages, 
where its value is without question. In country practice, 
where apparatus of the desired sort is not immediately 
at hand, a hot flat-iron and a paper cone answer admir- 
ably for directing mercurial fumes into the nasal pas- 
sages. The dose of calomel or of cinnabar selected for 
local fumigation must be reduced considerably from that 
used in the general bath. For the nose from 2 to 5 
grains of calomel may be vaporized; for the face a 
somewhat larger dose may be used. 

Hypodermatic Injection. — This method of introducing 
mercury into the system is properly described after the 
others, since, as a matter of practical experience, it is not 
only employed far less often than others, but promises 
to be reserved at no distant date for use only in special 
cases. By it the metal, pure or in combination, is in- 
jected directly beneath the integument. 

The advantages of this method are rapidity of effect, 
the sparing of the digestive tract (a feature which it 
shares wqth both fumigation and inunction), its simplicity 
and cleanliness as contrasted with the two methods 
named, and its surrender of the dosage into the hands 



246 SYPHILIS AND THE VENEREAL DISEASES. 

of the practitioner, and of him only — a feature of im- 
portance. Other advantages claimed, but not yet 
demonstrated to the satisfaction of experts, are the speed 
with which it effects a radical cure, the failure of relapses 
in the cases thus treated, and the exclusion of the 
gummatous phases of the disease. The objections to 
the method are great : it has often proved dangerous, 
and in a few instances fatal ; it is liable to produce fur- 
uncles, nodes, abscesses, sloughing, and other lesions at 
the site of injection ; it is likely to beget an overween- 
ing confidence on the part of both physician and 
patient that the disease is in course of radical treatment, 
while precious time is lost that might have been em- 
ployed in protecting the victim of the malady from its 
ravages at a future epoch. 

If, nevertheless, a hypodermatic mercurial treatment 
be selected, too much care cannot be taken in the prep- 
aration of the skin and the instruments before the oper- 
ation. Only sterilized solutions should be employed, 
and the skin over the region of introduction should first 
be cleansed thoroughly with warm water and soap, then 
dried, then washed with alcohol and dried, and then 
moistened with a I : looo solution of the sublimate. 
The needle employed should be of steel, gold, or silver, 
somewhat longer than that of the ordinary instrument, 
and in an aseptic state — as also, needless to add, should 
be the hands of the operator. The region most often 
selected for injection is the post-trochanteric, with the 
patient reclining on his belly and the muscles completely 
relaxed. The needle, with syringe attached and charged, 
taken from a 5 per cent, carbolized bath in a tray, should 
be pushed slowly down to the region where the salt is 
to be deposited, the physician avoiding always, first, 



TREATMENT OF SYPHILIS. 247 

entrance to a vein (known by the ease with which the 
syringe begins to discharge its contents, as contrasted 
with the obstruction encountered in muscle), next, re- 
gions of unusual pressure or friction, and, lastly, the 
inferior portion of the derma or very near the panniculus 
adiposus, where severe sloughing may follow. 

The damage resulting from hypodermatic injections 
of mercury may be the formation of nodes, abscesses, 
erythematous patches, and sloughing at the site of the 
deposit; alarming cardiac and pulmonary symptoms 
after injection within a vein ; sudden death ; exhaustion 
coming on slowly after the operation ; considerable pain, 
at times agonizing, at the site of the puncture; and 
salivation, with other systemic signs of the toxic action 
of the medicament. In well-managed cases, however, 
it is to be admitted that, with a properly constituted 
solution and with due precautions, hundreds of injections 
have been given with no untoward consequences. 

A great amount of literature exists on the subject 
of hypodermatic injections of mercury for relief of 
syphilis, and the list given of selected articles employed 
for the purpose is intended to serve chiefly as an index. 

Soluble Salts of Mercury. — Corrosive sublimate is 
employed for hypodermatic injections in the strength of 
from Y2 to ^ grain, dissolved in a few minims of water 
suspended in olive oil, or emulsified, as with vaseline or 
mucilage. The injections may be made as often as once 
every second or third day. The following are practi- 
cable formulae : 

!^. Hydrarg. chlor. corros., gr. j ; 

Glycerin., 

Aq. dest., aa. f3j. — M. 

Sig. Inject 10 minims. 



248 SYPHILIS AND THE VENEREAL DLSEASES. 



]^. Hydrarg. chlor. corros., 


gr. i; 


Sod. chlor., 


gr. f ; 


Aq. dest., 


fS-M. 


Sig. Inject 60 minims. 




^. Hydrarg. chlor. corros., 


gr. x: 


Acid, tartar., 


3ss; 


Aq. dest., 


flj.— M 



Sig. Inject 10 to 12 minims. 

Other preparations of this group are the following: 
Aspar agin- mercury. — -2^ drachms of asparagin are 
dissolved in warm water, and a saturated solution is 
made with the mercuric oxide ; this solution is filtered 
and diluted to a 2 per cent, mercuric solution, and \ 
grain of mercury is injected. The succinimide of 
mercury is injected in 5 per cent, aqueous solution, so 
that from -^ to 2V grain is employed at a dose. The 
oxycyanide of mercury is injected in doses of 15 grains, 
containing a trifle more than i per cent, of the metal. 
Bamberger's mercuiac albuminate ; Martineau's mercni'ic 
peptonate ; Stand's mixture of mercury, chloride of 
ammonium, chloride of sodium, and albumin ; and 
Gaillard' s combination of mercuric biniodide and sodium 
phosphate, are all too unstable to be worthy of reliance. 
Noiirrys formula for the iodo-tannate is as follows : 



Hydrargyri, 


gr-xV; 




lodini. 


gr.i; 




Acid, tannic. 


gi-- TO ; 




Glycerin., 


gtt. XV - 


-M 



Other soluble preparations which have been recom- 
mended are the carbolate of mercnry (^ to J grain for 



TREATMENT OF SYPHILIS. 249 

injection), the fonnamide in i per cent, solutions, the 
alaninate, and the benzoate, each of which has its 
partisans, and none of which has succeeded in achieving 
a large usage at the hands of experts. 

Insoluble Salts of Mercury. — Calomel, J to 3 grains 
suspended in a chloride-of-sodium solution, in mucilage, 
in glycerin, or in oil, has been injected every five to ten 
days, as well as metallic mercury, from 5 to 20 grains in 
a similar vehicle. 

Oleiun cinereum. (gray oi]) is made by emulsifying 
lanolin and chloroform and adding metallic mercury in 
double the quantity of the unguent : 20, 30, and 50 per 
cent, ointments are compounded with this basis, by the 
addition of olive oil. From \ to i grain of the 50 per 
cent, solution has been injected once or twice weekly, 
with progressively increasing intervals between the in- 
jections. Yellow oxide of mercury has been added to 
mucilage or olive oil and injected so that from i to 2 
grains have been used at a single dose. The black oxide 
of mercury is employed in 10 per cent, oil, in glycerin, 
and in gum emulsions; and cinnabar, in the strength of 
I grain suspended in oil. 

The conclusions which it is safest to accept, after 
reviewing the subject of hypodermatic injections in 
syphilis, have been well summarized by Dr. White of 
Philadelphia, who took pains to collate the opinions of a 
number of American experts on this question. The 
method has not as yet shown results which warrant its 
adoption as a means of routine treatment to the exclu- 
sion of, or in preference to, others : it has, on the con- 
trary, some apparently insuperable disadvantages and 
even dangers, which render it improbable that it will 
ever be generally adopted. 



250 SYPHILIS AND THE VENEREAL DISEASES. 

The Toxic Effects of Mercury (Hydrargyrism ; Saliva- 
tion ; Mercurial Pains, etc.). — Like most medicinal agents 
of well-marked efficacy, mercury, when improperly 
administered or when administered to peculiarly suscep- 
tible subjects, may produce toxic effects. Some of these 
effects ensue rapidly (so-called " acute " symptoms), 
others more slowly (the "chronic"). One of the most 
common and unpleasant of these results is salivation, an 
accident displayed in many grades. In the slightest 
grade there is moderate fetor of the breath ; slight in- 
spissation of the saliva ; some tenderness of the teeth, 
more particularly of the molars when brought together ; 
a sponginess of the gums, which bleed readily when 
pressed upon; a metallic taste in the mouth; and a 
peculiar pasty aspect of the dorsum of the tongue. All 
these symptoms may be exaggerated in various grades 
to the point where the parotid and submaxillary glands 
become tender and tumid, the saliva flows in a full 
stream from the mouth, the teeth are loosened and fall, 
the mucous membrane of the mouth becomes swollen 
and often eroded in patches, the tongue is swollen, pro- 
truded, and ulcerated, and the bones of the jaw are 
necrosed. The breath in all cases has an unmistakable 
and nauseous odor, and the patient is also generally in a 
depressed condition of mind and disturbed in most of 
the bodily functions. 

Among the results that develop more slowly may be 
named many of the evidences of gastro-intestinal dys- 
pepsia (inappetence, eructations, heartburn), progressive 
adynamia and anaemia, pains in the joints, occasionally 
limited to one of the larger joints and associated with 
temporary immobility from pain, and symptoms simu- 
lating those of muscular rheumatism. While there is a 



TREATMENT OF SYPHILIS. 2^\ 

large list of ailments, not here set down, popularly ac- 
credited to the toxic effects of mercury, it may be said 
of most of such symptoms that they are due either to 
syphilis or to some other cause, and are wrongly imputed 
to the action of the metal. We have never been able to 
persuade ourselves that for any reasonable period after 
the ingestion of mercury had been suspended (months at 
the longest) any general effects of it are perceptible in a 
previously healthy subject ; and the records of the physi- 
cians in charge of the laborers in mercury-mines attest 
the same fact. There the toxic effects are distinct and 
often grave, severe salivation being more or less rapidly 
followed in all grave cases by osseous necrosis. Nothing 
is found in these records corresponding with the " chronic 
rheumatic disorders," " eruptions upon the skin," and 
other ailments popularly charged to a continued use of 
mercury, and occurring years after its suspension. 

Let it be noted further that in the few cases where, 
early in a syphilitic career, mild salivation has acci- 
dentally occurred (the writers have seen but few cases 
in many years), the issue is not altogether without its 
bright side. As a matter of fact, the few salivated 
patients have in the results obtained compared most 
favorably with others ; and in one specially dangerous 
and extreme case, where salivation was intentionally pro- 
duced, the issue was in the highest degree satisfactory, 
as a valuable life seemed thereby to have been saved. 

When mercurial stomatitis supervenes, with symptoms 
of salivation, the metallic dose, if the case is not ex- 
ceedingly urgent, should at once be suspended and the 
diet be limited to nutritious foods in a liquid or a semi- 
liquid state (broths, cream, soft-boiled eggs, etc.). The 
fluids used for drinking should be neither hot nor cold, 



252 SYPHILIS AND THE VENEREAL DISEASES. 

and all salted, spiced, and acetous articles of diet should 
be forbidden. The mouth should be washed frequently 
with bland lotions of flaxseed tea or borated or car- 
bolated fluids, always diluted, such as ; 

^. Potass, chlorat., 3J ; 

Mel. despum., 

Myrrh, tinct., aa. f^ss ; 

Aq. dest, ad f^viii.— M. 

Sig. To be used as a mouth-wash and gargle, diluted 
with tepid water until grateful to the surface. 

Often during the day the gums should be rubbed 
gently but thoroughly, within and without the circle 
of the teeth, with a tepid myrrh-and-cinchona wash 
(equal parts of the tincture of each suspended me- 
chanically by shaking in water) applied by means of 
a soft piece of linen wrapped about the forefinger. We 
invariably order iron internally in these cases, and if 
any specific medication is employed before the toxic 
effects subside, we employ in small doses one of the 
salts of iodide. Recovery under good treatment is in 
any well-managed case rapid and complete. 

Iodine and its Compounds. — With relation to the 
therapy of syphilis, iodine and its compounds stand next 
after mercury in popular estimation; and if just reserve 
be made, they certainly stand in this relation when 
properly employed in selected cases. There are two 
axioms that still very largely influence the minds of pro- 
fessional men on this question : one is that while mercury 
is most valuable in early periods of syphilis, the com- 
pounds of iodine are chiefly valuable in the late or gum- 
matous periods ; another is that while mercury cures 



TREATMENT OF SYPHILIS. 253 

the disease, the compounds of the other metal reheve 
without curing. Both axioms are imperfect generaliza- 
tions of a wide experience, which must, however, not be 
permitted to warp the judgment of the practitioner in 
any case where the one or the other drug is chiefly in- 
dicated. 

The following are conditions in which it is common, 
and in general wise, to employ the iodine compounds: 

First: In all attempts to resolve gummatous lesions 
promptly, the iodides are wellnigh unequalled in the 
armamentarium of the expert. Here (as in gummata of 
the brain, the testis, the liver, the spleen, or the kidney) 
life may be saved by their efficient employment, and in 
other cases (gummata of the periosteum, the meninges, 
etc.) a great amount of suffering may be spared. 
Second : The iodides are often in the highest degree 
valuable in any stage of syphilis when the patient 
either is intolerant of mercury or, if sufficiently tolerant, 
cannot be made, when ingesting it, to gain in weight, in 
appetite, and in the proper performance of his functions. 
Third : When it is desired to produce a profound im- 
pression on a syphilitic lesion, and the patient is being 
subjected to the action of mercury by any of the methods 
of its external employment (fumigation, inunction, etc.). 
Fourth : The iodides are in some cases, not as a routine 
treatment, valuable as furnishing an alternate medication 
of patients long subjected to the action of mercury. 

It is exceedingly doubtful if, as was once thought, the 
iodide of potassium aids in the elimination of mercury 
previously introduced into the system. The speedy 
effects of the salt are well known, and Its rapid appear- 
ance in the urine after ingestion (as shown by starch and 
other tests) is readily demonstrable. When the patient 



254 SYPHILIS AND THE VENEREAL DISEASES. 

is under its influence the application of starch to the 
tongue produces there a blue color, and the nitrate of 
silver a yellowish tinge, as a consequence of the result- 
ing double decomposition. 

The brilliant results which the iodides in selected 
cases are capable of accomplishing, and the dread of 
producing ill effects by the action of mercury, have 
buttressed the great popularity of the former with the 
general practitioner and with the public. Iodine and its 
compounds are represented in almost all the proprietary 
preparations sold in the shops for the relief of syphilis. 
Iodine is the one remedy earliest and most often resorted 
to by the ignorant, and it is the one which is last used, 
and then most effectively, by the expert. Given the 
patient who has been relieved of syphilis without a resort 
to iodine, and his case has probably been managed better, 
and is more secure as to its future, than that of another 
in which a large use has been made of the iodine salts. 

The best known preparations are the iodides of potas- 
sium, sodium, lithium, strontium, starch, and rubidium ; 
but the iodide of potassium has long held its own at the 
head of the list, and it gives promise of doing so for 
years to come. While given often in combination with 
other drugs, it is by no means settled that these combi- 
nations (save with mercury, as described later, possess 
any value over the simpler solutions. Of these solu- 
tions, none is better than that made by adding an 
ounce of the iodide of potassium to a fluidounce of dis- 
tilled water ; but as this combination often deposits the 
salt by precipitation about the cork of the vial after a 
brief interval, and as it is at times somewhat difficult of 
digestion, the iodide is often administered in drop doses 
from a solution made by adding half an ounce of the 



TREATMENT OF SYPHILIS. 255 

potassic salt to an ounce of the essence of pepsin (Fair- 
child's or another). The first formula has the advantage 
that it may be given, when that article of food does not 
disagree with the patient, in milk as well as in water. 

The dosage of the iodide depends almost wholly on 
the emergency presented in any case where it is thought 
best to employ it. In uncomplicated cases it may be 
administered in teaspoonful doses of a solution contain- 
ing 5, 10, or 20 grains to the drachm; but in cases 
where an emergency has arisen it is customary with ex- 
perts to order one of the stronger solutions named above, 
and, beginning with drop doses, to increase gradually 
either one drop per diem, or one or even two or more 
drops each dose, until much larger doses are reached 
than are usually employed in cases where no emergency 
exists. In these cases large, and even extremely large, 
doses are slowly reached and for long periods of time 
steadily maintained. In this way 300, 400, 600 grains, 
and even more, of the iodide of potassium have been 
given in twenty-four hours, and with favorable results as 
respects the object in view. In reaching the larger 
doses the following rules should be observed : (ci) The 
dose should not be increased after the occurrence of any 
of the serious symptoms of iodism, described later ; {b) 
nor if constipation of a marked character occurs ; {c) nor 
if any decided indication of trouble occurs in the urine 
(albuminuria, etc.) ; (d) nor if the immediate effect in 
view is secured (relief of a dangerous cephalalgia in 
syphilitic meningitis ; relief of torturing pain at night 
from an osteoperiostitis, etc.). 

The articles added to solutions of the iodide of potas- 
sium with a view to improve its efficiency or to prevent 
iodism are yearly accorded less and less favor, though 



256 SYPHILIS AND THE VENEREAL DISEASES. 

once held in high esteem. Thus the chloride of am- 
monium in doses of 5 grains and the carbonate of am- 
monium in doses of 10 grains were thought to increase 
the efficiency of the iodine salt, while arsenic and arseni- 
ous acid were added with a view to the prevention of 
iodic acne. 

A great number of remedies, mostly from the vege- 
table kingdom, have been extolled for years as not merely 
of themselves sufficient to "cure " the disease, but, fail- 
ing that, to add to the value of the iodide of potassium 
by assisting in its assimilation and by giving tone to the 
stomach. It would be a waste of space to enumerate 
these remedies, beginning with sarsaparilla, which even 
at this late day still holds sway over the minds of the 
credulous, and ending with the " McDade " formula: 

^. Smil. sarsaparilla, fl. ext.. 
Stilling, sylvat., fl. ext, 
Kappae minor., fl. ext., 
Phytolacc. decand., fl. ext, da. f^ij ; 
Xanthoxyl. Carolin., tinct., f^j. — M. 

Sig. Teaspoonful to tablespoonful doses in water before 
food. 

None of these " vegetable " remedies can be demon- 
strated to have any curative effect upon syphilis, apart 
from the metallic salts with which it is usual to com- 
pound them. They are never ordered by the writers, 
for, if merely a tonic and carminative effect be desired, 
much more valuable remedies are available. Strychnia, 
quinine, and iron or the mineral acids, the latter often 
in conjunction with a mild mercurial, are superior from 
every point of view to all of the " vegetable infusions 
and decoctions." 



► 



TREATMENT OF SYPHILIS. 257 

The fluid extract of coca, much praised by Taylor, 
stands on a different footing, since it is not claimed in 
any sense to be a specific for the disease, but only a 
valuable agent in exerting a tonic effect upon the ner- 
vous, vascular, and lymphatic systems. We have used 
the coca in many cases with great advantage both in 
the form of the wine (Mariani, Metcalf) and in that of 
the fluid extract, as follows : 

!^. Erythrox. coc, fl. ext, f^ij ; 

Gentian., tinct. co., 

Cinchon., tinct. co., aa. fgj ; 

Elix. calisayae, f^iv. 

Sig. A tablespoonful in water after food. 

If^. Erythrox. coc, fl. ext, f|ij ; 

Cinchon., tinct. co.. 

Gentian., tinct. co. aa. f^ij. 

Sig. Two teaspoonfuls in water after food. 

Toxic Effects of the Iodine Compounds. — lodism, or the 
symptoms of toxic effects after the ingestion of the com- 
pounds of iodine, is much more frequent than the pro- 
duction of toxic effects by mercury, on account of the 
rapidity with which iodine affects the system, and also 
on account of the far larger number of persons suscep- 
tible to such effects. In discussing this subject it may 
for practical purposes be assumed that the iodide of 
potassium is the remedy selected, seeing that it is the 
most commonly ingested of all the iodine compounds 
employed in the treatment of syphilis. 

Like all drugs exerting in any degree a toxic effect, 
the iodide of potassium will often display its mischievous 
energy after but a small dose has been administered — 
17 



258 SYPHILIS AND THE VENEREAL DISEASES. 

even so small as i or 2 grains. In other cases the toxic 
results are declared only when very large doses are 
reached. It is the popular and semi-professional belief 
that some persons have a special idiosyncrasy forbidding 
them ever to make use of the drug, but that in many 
patients, by care and a skilful adjustment of the dose, 
there can be established a "toleration" which will enable 
the vast majority to ingest even the largest quantities. 
There is truth, probably, on both sides of this question, 
though its final determination is difficult. With the 
employment of the graduated dose, with the bowels 
freed from irritating contents, with the habits of life 
regulated as carefully as they always should be in the 
subject of syphilis, the end sought can generally be 
attained. The toxic symptoms of iodism may be of the 
very slightest grade (the occurrence of one or two irri- 
table nodules over the face), or they may have grave 
sequences which may be in the highest degree alarming. 

It has been said of the iodide of potassium that it is 
capable of producing upon the skin a picture resembling 
that of every cutaneous affection, and this statement is 
certainly suggestive of an interesting series of facts. The 
lesions produced in the skin are usually of the acne 
type, and limited to the face, the shoulders, the neck, 
and the upper portion of the trunk — the regions chiefly 
affected by the disease named. Classified, they range 
between macules and papulo-pustules, tubercles, nodes, 
bullae, and phlegmonous, purpuric, and ulcerative lesions. 

Other symptoms are the production of a metallic taste 
in the mouth, salivation, coryza of a persistent type (often 
with an exceedingly abundant serous discharge from the 
nares), and several forms of urticaria, verging in ex- 
treme cases to the type of angioneurotic oedema, with 



TREATMENT OF SYPHILIS. 259 

spasm of the glottis when the swelHngs occur in this 
region, dyspnoea, and involvement of the joints. In other 
cases all the symptoms of peritonitis are present, with 
tumefaction of the belly, intense pains, constipation, and 
fever. Other toxic effects are slower of evolution, 
and are exhibited in a progressive anorexia, weakness, 
decolorization of the skin (of anaemic type), and decided 
loss of sexual desire and vigor. As a rule, the toxic 
effects of the iodide of potassium speedily disappear 
when the exhibition of the remedy is suspended and 
one of the tonic methods of treatment is substituted. 
When the anaemia from long-continued use of the iodide 
is added to the cachexia of syphilis, the result is espe- 
cially unfortunate, and only the clear eye of an ex- 
perienced physician can precisely discriminate between 
the two. 

Mixed Treatment. — The term " mixed treatment " has 
been employed to designate the method by which 
mercury and the iodine salts are employed in combina- 
tion in the treatment of syphilis. It is obvious that they 
may be administered simultaneously when mercury is 
introduced either by inunction, by fumigation, or by 
hypodermatic injection, and the iodides are at the same 
time given by the mouth ; also w^hen at one time in the 
day a mercurial and at another an iodide dose is 
ordered ; and, lastly, when mercury and a salt of iodine 
are administered at the same time in a single dose. It 
is for the combination last named that the title " mixed 
treatment " has been especially reserved. 

The following are a few of the " mixed " formulae most 
often employed toward the end of the first year of 
syphilitic treatment, or earlier when there is a special 
indication for the use of the iodides, as when gumma- 



260 SYPHILIS AND THE VENEREAL DISEASES. 

tous, tubercular, nodular, or threatening lesions persist 
upon the skin or over the mucous membranes, refusing 
to yield to mercury alone : 

^. Hydrarg. biniodid., grs. j-iij ; 

Potass, iodid., ^ss-ij ; 

Syr. aurant. cort., fgiij ; 

Aq. dest, ad f^vj.— M. 

Sig. A teaspoonful in a wineglassful of water after food. 

At times the bitter tinctures are added to formulae of 
this character, in order to produce a tonic effect ; but, as 
already pointed out, it is in general better in syphilis to 
administer tonics separately and before meals, seeing 
that the dose of the tonic remedy is commonly fixed, 
while it is often of service to administer the mercurial 
in a dose that can be changed so as to increase or 
decrease, when required, the amount of the metal in- 
gested. 

The decomposition of the mercuric bichloride by the 
iodide is often practised in compounds of the " mixed " 
class, but as there is some uncertainty about the result 
in different solutions, it is better to order the biniodide. 
Bichloride combinations with iodide of potassium are 
usually made as follows : 

^. Hydrarg. bichlorid., gr. j-iij ; 

Potass, iodid., iss-ij ; 

Glycyrrhiz., syr., f^ij ; 

Aq. dest., ad f^vj.— M. 

Sig. A teaspoonful in water after food. 

The Treatment of Syphilitic Lesions as they are 
Presented in the several Organs of the Body. — The 

treatment of chancre has been discussed in the pages 
devoted to that subject (pp. 51-57J. 



TREATMENT OF SYPHILIS. 26 1 

Syphilis of tlie skin is amenable to the treatment appro- 
priate to the systemic state, but at times, especially when 
the lesions are localized and asymmetrical, local treat- 
ment is of especial value. 

The erythematous and papular syphilodermata, when 
persisting on the exposed surfaces of the body (face, 
hands, etc.), may be sponged with warm water at night 
and afterward anointed with — 

Ij^. Hydrarg. ammon. (vel. chlorid. mit.), gr. v-xx; 
Bals. Peruv., TtLx; 

Unguent, aq. ros., §j. — M. 

Sig. External use. 
Or, when a lotion is preferred, the parts may be sponged 
with a solution of the bichloride in rose-water, J to I 
grain to the ounce ; or the following may be used : 
15^. Hydrarg. chlor. corros., gr. ij ; 

Vin. rect., spt, 
Benzoin., tinct, 

Tolutan., tinct., aa. iZ] ; 

Glycerin., fsj ; 

Aq. ros., ad f gvj.— M. 

Sig. Shake. External use. 
When seborrhoeic crusts form about the forehead, 
nose, lips, ears, etc., the following may be employed 
with advantage : 

15^. Hydrarg. sulph. rub., gr. j-ij ; 
Sulph. praecip., 3j ; 

Bals. Peruv., tltx ; 

Unguent, aq. ros., 5i- — ^• 

Sig. External use. 
Vaseline should be ordered as a salve-basis when the 
unguent is to be applied over a hairy region. Resorcin 



262 SYPHILIS AND THE VENEREAL DISEASES. 

is useful, in the strength of from a scruple to a drachm 
of ointment. 

For the papular and scaling lesions, which are often 
obstinate, especially over the palms and the soles, noth- 
ing is better than mercurial ointment in full strength, or, 
in regions where the skin is tender, in the strength of 
one-half, one-quarter, or less. Lesions of the palms and 
the soles, when persistent, require preliminary softening 
with warm water and green soap, the parts being well 
shampooed, especially at night, before the application 
of the salve, the latter being kept in contact with the 
skin during the hours of sleep. The ointment of the 
nitrate of mercury in the strength of 2 drachms to the 
ounce may often be added with good effect to the 
Wilkinson salve ^ or to an unguent compounded by 
adding to an ounce of lard from J to i drachm of one 
of the tars (oleum rusci, oleum cadini, oleum picis) and 
from I to 2 drachms of precipitated chalk, the whole 
being compounded secundum artem by boiling, sifting, 
and stirring. The articles found useful in non-syphilitic 
papular and scaling lesions (chrysarobin, salicylic acid, 
and ichthyol) may here also often be used with profit. 
The soothing salves (diachylon ointment, oleate of 
bismuth, and benzoinated zinc ointment freshly prepared) 



* R . Sulphuris sublimat., 




01. rusci, 


aa. 3ij ; 


Sapon. virid., 




Adipis, 


aa. ^ss; 


Cretae prseparat., 


gr. Ixxv. 


Sig. External use. 





-M. 



The best oleum rusci should be used in preparing this ointment ; but if 
the best cannot be obtained, either the oleum picis or the oleum cadini 
may be substituted for it. If possible, use the oleum rusci having the 
peculiar odor of Russian leather. 



TREATMENT OF SYPHILIS. 263 

may also be used, adding, to the latter particularly, the 
mercurial specially indicated. 

Condylomata, secreting papules, warts, vegetations, 
etc. about the ano-genital parts and over the axillae, the 
groins, and elsewhere are readily relieved. They are all 
foul-smelling, and they require deodorizing solutions of 
chlorinated soda or of boric acid, after which they are 
to be dusted thoroughly with equal parts of calomel and 
starch or with boric acid. The apposed surfaces are 
to be separated by the interposition of antiseptic lint. 
For the dusting-powder named may be substituted euro- 
phen (which is usually very comforting in its relief of the 
odor and the pruritic condition), hydronaphthol, or iodol. 
Where the warty growths are exuberant they may be 
painted with solutions of the bichloride in flexile col- 
lodion, yi, scruple to the ounce, or with a modification 
of the well-known wart-cure formula : 

]^. Acid, salicylic, Bj-^j >* 

Extr. cannabis indie, 9ss-j ; 

Collodion, flexil, ij.— M. . 
Sig. To be painted over the part. 

By thorough treatment with these and similar solu- 
tions it will very rarely be necessary to employ severer 
measures. The actual cautery, the curette, and the 
several caustics may, indeed, be employed, but in general 
this course indicates a lack of skill on the part of the 
physician in his employment of the simpler measures. 

Pustular lesions, crusted or ulcerated, especially over 
the face, require careful attention, since the production of 
scars in this region may mark the patient for life. It is 
well to remember, in the management of all such emer- 
gencies, that they represent a mixed infection, and that 



264 SYPHILIS AND THE VENEREAL DISEASES. 

the staphylococci are to be combated. All crusts should 
be removed by repeated hot borated washings, after 
which the surface, if thoroughly cleansed, may first be 
wiped with alcohol or touched with a solution of the fol- 
lowing sort : 

^. Hydrarg. chlor. corros., gr. j-ij ; 
Benzoin., tinct, f^j. — M. 

Sig. For external use only. 

One of two courses may then be pursued : The skin-sur- 
face may be dusted with calomel, europhen, boric acid, 
or hydronaphthol, and over all there may be applied a 
delicate film of cotton fastened at the edges to the sur- 
face with a light layer of flexible collodion ; or face- 
plaster may be superimposed over the cotton ; or a film 
of collodion may be applied over the powder directly. 
An alternate course is to apply as a dressing one of the 
mercurialized pastes : a little practice will suggest from 
day to day, to both practitioner and patient, which paste 
best serves the special indications. From i to 20 grains 
of ammoniated mercury or calomel may be added to the 
Lassar paste (the formula for which has already been 
given), or I or 2 drachms of mercurial ointment, each in 
place of the salicylic acid usually ordered in the combi- 
nation named. 

When pustular or gummatous lesions of either the 
skin or the subcutaneous tissue break down to form a 
syphilitic ulcer, the treatment in each event is the same. 
All crusts are to be removed thoroughly — if need be, by 
soaking and washing in hot borated water as described 
above — all sloughs are to be plucked away or curetted, 
and the surface is to be made as clean as possible. The 
floor and the edges of the ulcer are then freely and 



TREATMENT OF SYPHTLIS. 265 

deeply cauterized either with the nitrate of silver in stick 
or in solution or with fuming nitric acid. Delay should 
be made in the after-dressing until all oozing has ceased, 
after which one of the powders is to be applied, followed 
by an antiseptic compress and, when practicable, a band- 
age. The latter is chiefly valuable over the lower ex- 
tremities, where support is as imperatively required for 
most syphilitic ulcers as for those of eczemato-varicose 
type. The flannel bandage cut on the bias answers well 
for patients unable to apply skilfully the common roller 
bandage over leg or arm ; and for those able to afford 
the slightly greater expense the silk elastic stocking is 
both convenient and in a high degree useful in the way 
of support. In this event we are in the habit of order- 
ing for use next the skin, by both sexes, a long white 
cotton stocking such as is usually worn by women, 
the elastic silk support being drawn over the stocking. 

In all indolent ulcerations of the extremities support is 
readily effected, after dusting with an appropriate powder, 
by dressing with superimposed strips of rubber or of 
adhesive plaster encircling two-thirds of the circumfer- 
ence of the limb. Internally the treatment of these 
ulcers is best conducted by the " mixed " method, the 
iodide being usually demanded in the fullest doses, and 
the mercurial at the same time by inunction or by addi- 
tion to the iodide by the mouth in one of the " mixed " 
formulae. 

In the early forms of syphilitic alopecia not obviously 
due to changes in the scalp, it is well to clip or cut the 
hair short and to shampoo the scalp three or four times 
in the week with the tincture of green soap flavored 
with lavender-water or cologne -water. After such 
shampooing, and also, at times, when none is employed, 



266 SYPHILIS AND THE VENEREAL DISEASES. 

the following lotion may be well rubbed into the sur- 
face : 

^. Cantharid., tinct., fij ; 

Hydrarg. chlor. corros., gr. j-iij ; 
Capsici, tinct., 

01. sesami, aa. f|ss ; 

Spts. vin. rectif , f |ij ; 

Aq. ros., ad f^viij. — -M. 
Sig. External use over the scalp. 

When crusts form upon the scalp, they should be re- 
moved by the. shampoo ; a salve may often afterward be 
employed, such as ammoniated mercury (or calomel), 5 
grains to the ounce of vaseline, or precipitated sulphur 
I drachm and cinnabar i grain to the ounce of the same 
salve-basis. 

In the management of syphilitic lesions of the mouth 
it has already been shown that prophylaxis is of prime 
necessit}^. The exclusion of tobacco in every form, the 
stopping of all carious teeth, and the removal of those 
requiring extraction should be secured at the outset. 
The chewing of gum, the constant holding in the mouth 
of a toothpick v/hich is practically chewed, and even 
the sharp edge of a sound tooth against which the 
tongue plays, may each be responsible for a deeply 
extended ulcer. All mucous patches should be touched 
daily, or twice daily when practicable, with either a 5-, 
a 10-, or a 20-grain solution of the silver nitrate, or by 
the solid stick, which can be used freely in the hand of 
an expert. It is, however, quite unsafe, as a rule, to en- 
trust silver solutions and caustic to patients themselves 
or to their friends, as the abuse or the misuse of this 
valuable agent follows in a great percentage of cases. 



TREATMENT OF SYPHILIS. 267 

For individual use the milder washes, lotions, and gar- 
gles may be ordered, such as — 

I^. Potass, chlorat., 3J ,* 

Mel. despum.. 

Myrrh., tinct., aa. fgss ; 

Aq. dest, ad f,!vj.— M. 

Sig. To be used, diluted with water as required, in the 
throat. 

A teaspoonful of this solution in a third of a tumblerful 
of pure water will usually be found grateful. For it may 
be substituted i drachm of the potassic chlorate in 6 
ounces of peppermint-water, or a few drops of the fol- 
lowing modification of Bellamy's iodized phenol : 
li. Acid, carbolic, 3J ; 

lodin., tinct., f 3ss ; 

Glycerin., 

Spts. vin. rect, da. f 3ij ; 

Aq. dest, ad f5J.— M. 

Sig. Ten to fifteen drops in large dilution as a mouth- 
wash and a gargle. 

" Listerine," a proprietary preparation, is popular with 
many patients (it is chiefly a weak distillate of eucalyp- 
tus), diluted as required. Mercurial washes are also ad- 
vised from I to 4 grains of the sublimate being added to 
the half pint of water, with tincture of myrrh and honey 
in the proportions already given. The objection to 
these washes is the possibility of the solution being 
accidentally swallowed, and for that reason other local 
remedies are to be preferred. The compressed tablets 
containing 5 grains each of the potassic chlorate may 
also be used, a half dozen or more, in case of need, being 
dissolved in the mouth and swallowed daily. In all in- 



268 SYPHILIS AND THE VENEREAL DISEASES. 

dolent cases, especially where the drug is indicated in- 
ternally, we are in the habit of administering quinine, 
a few grains each day being laid upon the tongue, the 
local bitter effect of the alkaloid speedily diffusing itself 
through the mouth. Gummatous lesions require the 
use of the stronger caustics and call for the iodide of 
potassium internally in ample doses. In extreme cases 
only should the galvano-cautery be used. When the 
soft or the hard palate is involved, the medication of 
the patient should be prompt, as remediless damage may 
be inflicted in a single day. The iodide of potassium 
may be pushed rapidly to the largest tolerated dose, a 
mercurial is usually employed by inunction, and caustics 
are used freely in order to stimulate the engorged tissue 
to a healthier activity. In these cases, as in those of the 
milder mucous and scaling patches of the mouth, all very 
hot, very cold, acetous, salted, and highly-seasoned 
articles of food and drink should sedulously be excluded 
from the mouth. 

Nasal lesions of syphilis require the internal treatment 
indicated in each particular case, but the local manage- 
ment is of importance. The solutions of nitrate of 
silver and the application of the crayon itself are in the 
first rank of local importance, the strength of a solution 
and the severity of the application being determined by 
the physician on the basis of the grade of the lesions 
present. Local fumigations with mercury, as already 
shown, are of great value in all cases of severity ; and 
unguents of the yellow oxide or of ammoniated mercury, 
I grain to the ounce of cold-cream salve, may be applied 
after the use of a caustic solution. Douches are re- 
quired in all cases of ozaena ; they are to be prepared 
with chloride of sodium, i drachm to the pint of distilled 



TREATMENT OF SYPHILIS. 269 

water, one or more drops of Bellamy's iodized phenol 
to a few ounces of the same, or a weak borated wash. 
The following vapor may advantageously be snuffed 
into the nostrils in cases of ozaena : 



Acid, carbolic, 


.5j; 


lodin., tinct. 


f3ss; 


Aq. ammon.. 


f 3ij ; 


Aq. cologniens., 


ad f ^j. 



I 



Place in a two-ounce glass-stoppered vial, half filled with 
cotton, and designate : *' Vapor for snuffing through 
the nostrils." 

All sequestra of bone require removal by accepted 
surgical measures, care being taken lest forcible removal 
before the pieces of bone are entirely separated from 
their connections result in severe shock or, as has 
happened, in fatal hemorrhage. The snare and the 
electro-cauteric apparatus may be needed in special 
cases. 

Pharyngeal lesions resulting in stenosis or in adhesions 
are to be treated like similar sequelae in the larynx — 
with blunt or cutting dilators, the knife, or the galvano- 
cautery. Excellent results may be obtained in all mild 
cases by albolene sprays medicated with menthol (i to 2 
grains to the ounce), with carbolic acid, with pinus Cana- 
densis, or with iodized phenol solution (20 drops to the 
ounce of albolene). Caustics (nitrate of silver, chromic 
acid) are required for touching papillomatous and other 
growths. In syphilis of the larynx and of the trachea 
much good often results from mercurial inunction of the 
overlying skin. In general, the iodide of potassium is 
indicated internally; in mild cases, however, or in those 
not threatening, the " mixed " treatment answers well. 



2/0 SYPHILIS AND THE VENEREAL DISEASES. 

The nails, when involved in syphilitic changes, require 
special attention. Besides the constitutional treatment 
required in all cases, the digits should usually be pro- 
tected from injurious contacts by cots. In gummatous 
lesions the iodide or the " mixed " treatment is indicated 
internally, and in non-ulcerative forms a weak mercurial 
salve may be applied. In ulcers of the soft parts about 
the nail caustic applications followed by dusting with 
europhen or calomel are needed. However great the 
apparent deformity, and however exquisitely painful the 
ulceration, after immersion in warm borated water fol- 
lowed by dusting-powders, and the gentle but firm com- 
pression of the parts with antiseptic cotton between 
bandage and ulcer, the dressing may be made both 
efficient and comfortable. In gouty and cachectic states 
special treatment is required to obviate these conditions. 

Syphilis of the bones and the periosteum calls in 
general for treatment by iodide of potassium, to relieve 
the osteocopic pains and tumefaction, while mercury is 
needed to ensure against trouble in the future. In many 
of these cases the " mixed " treatment answers well. 
Externally, when the osseous tissue involved is within 
the reach of such treatment, mercury is of the highest 
value, unguents and oleates of mercury being chiefly 
employed. Mercurial plaster is often serviceable when 
cut to the proper shape and more or less continuously 
worn over any accessible nodes or tumors. It is rarely, 
if ever, necessary to incise local gummatous deposits ; 
and any sequestra formed as a result of syphilitic caries 
or necrosis should be removed surgically only when 
completely separated. The familiar surgical procedure 
of making long incisions the length of a bony '' splint " 
along the tibia is, in syphilitic cases, for the most part 



TREATMENT OF SYPHILIS. 2'Jl 

wholly unnecessary and without value. Surgical interfer- 
ence is on rare occasions required when there is pressure 
upon a nerve-trunk by an osseous or osteo-periosteal 
tumor. All abscesses require proper surgical opening 
and drainage. Separation of an epiphysis demands cor- 
rection of any resulting deformity, and immobilization 
of the limb by the aid of a splint. 

Plastic operations are often of decided value in cor- 
recting the most hideous of the facial deformities pro- 
duced by bone-syphilis ; and in grave cases an artificial 
nose may be worn. Sinking of the nasal bridge is well 
corrected by platinum and other supports. In dactylitis 
syphilitica amputation should almost never be practised. 
Great relief can be obtained by medical treatment (iodide 
of potassium internally), by mercurial frictions where 
there is no degeneration of tissue, by incision of all 
suppurating tissue (in lines parallel with the long axis of 
the limb in the effort to avoid wounding tendons), and 
by strict observance of antiseptic precautions. 

The viscera, when the seat of the lesions of syphilis, 
require, for the most part, internal treatment, which is 
to be pursued according to the indications in each 
case. It has already been noticed that the suggestion 
that syphilis is a possible cause of aneurysm was origi- 
nally due to the recognized value of iodide of potassium 
in that affection. In syphilis of the heart, lungs, liver, 
kidney, and spleen the iodide of potassium, occasionally 
in combination with mercury, is indicated, and in many 
cases is of great service. In other cases, especially when 
degeneration of cells has been wrought, the treatment, 
while not always curative in its results, exhibits a marked 
power in arrest of the malady. In all cases of visceral 
syphilis, however, there is urgent need of systemic treat- 



272 SYPHILIS AND THE VENEREAL DISEASES. 

ment beyond that which might strictly be called " anti- 
syphilitic," patients being often in a cachectic or anaemic 
state. Special complications also arise (ascites, albumin- 
uria, cough, haemoptysis, jaundice, etc.), requiring the 
particular treatment recognized in general medicine as 
appropriate to each. 

Syphilitic lesions of the rectum and the anus always 
demand special attention. By the aid of nitrate of silver 
in solution (from 5 to lo grains to the ounce) all fissures 
of the anal folds may be stimulated, and they may be 
dressed subsequently with iodol or europhen powders 
with superimposed lint. Before each stool, the rectum, 
as far as can readily be reached with the finger, is to be 
well smeared with the following : 

]^. Benzoin., tinct, f 5j ; 

Unguent, aq. ros., 
Vaselin., aa. ^ss. — M. 

Sig. For external application with the finger as directed. 

Enemata of warm water must be ordered if the bowels 
are impacted. 

All gummatous lesions call for iodide of potassium in 
the largest doses required to secure involution, mercury 
being at the same time carefully and judiciously em- 
ployed. Strictures of the rectum are to be treated 
at first with dilatation by rubber bougies, care being 
taken not to rupture the gut and induce a peritonitis. 
When, as is too often the case, the result is a mere 
temporary benefit, the last resorts are posterior proc- 
totomy, division of stricture by the galvano-cautery, 
inguinal colotomy, and complete excision of the 
neoplasm, as in case of carcinoma. In emergencies re- 
quiring surgical interference we have found inguinal 



TREATMENT OF SYPHILIS. 273 

colotomy most serviceable. In a few instances, after 
the irritation produced by the passage of faeces over the 
rectum has been removed, the latter organ has under 
treatment returned to a condition permitting of closure 
of the artificial anus in the groin. As most of the 
subjects of this disorder are women, the pain attending 
subsequent menstruation often requires attention. 

Syphilitic lesions of the epididymis and body of the 
testicle are usually amenable to treatment with iodide of 
potassium internally and mercury externally, the latter 
employed in the form of either the oleate or the oint- 
ment. Many of these cases call for prompt and energetic 
treatment to avert aspermatism, which too often ensues 
even if atrophy does not follow absorption of the gum- 
matous mass. An accompanying hydrocele usually re- 
quires tapping. Even after implication of both testes 
it is often difficult to persuade patients of the need of 
absolute disuse of the sexual organs. 

Lesions of the nervous system, whether of the brain, 
the meninges, or the cord, usually require internal treat- 
ment of similar character in each complication. It has 
been customary to employ in these cases the largest 
tolerated doses of iodide of sodium or iodide of potas- 
sium ; and the result in favorable cases is as brilliant as 
it is satisfactory. One of these salts, or both in combina- 
tion, may be administered in a saturated solution in drop 
doses, the vehicle being milk, alkaline water, or an es- 
sence of pepsin taken before or after meals, with another 
dose at bed-time. In all emergency cases it is well to 
disregard the hours of meals, and to administer the 
remedy every four hours during the wakeful periods of 
the day and night. By the addition of I or 2 drops of 
a saturated solution either to each or to each third or 

18 



274 SYPHILIS AND THE VENEREAL DISEASES. 

fourth dose, very large quantities of iodide of potassium 
have been taken with favorable results, an ounce and 
even two ounces and more having been thus ingested 
within twenty-four hours. For the caution requisite in 
the attainment of and persistence in these large doses 
the reader is referred to preceding pages devoted to the 
subject of the employment of the iodides. 

Inunctions of mercury at the same time with the 
medication may generally be practised with the best 
results ; while the " mixed " treatment is to be reserved 
for cases exhibiting no signals of danger and calling for 
no specially energetic management. 

The belief, however, is now gaining ground that too 
much stress has in the past been laid upon the treatment 
of nervous syphilis with the iodine salts, and that the 
great value of mercury has needlessly been ignored in 
these grave complications of the disease. We are in the 
habit, in all severe cases, of carefully testing the condi- 
tion of the patient by giving -^ grain of calomel, or even 
more, every hour until a decided effect has been pro- 
duced ; and certainly the gravest types of pachymen- 
ingitis have thus been relieved. Tonics are demanded 
in all cases of nervous syphilis where the crisis of the 
disease has been combated successfully, and often before 
such an event. The diet should be in a high degree 
nutritious, the feet are to be kept warm, and tobacco and 
alcohol are rigidly to be excluded. For the majority of 
patients we are opposed to the employment of hot baths 
in nervous syphilis, preferring, in general, the daily 
sponging of the body-surface with a strong solution of 
salt and water followed by frictions with the flesh-brush. 
Fumigations also, valuable though they may be in other 
syphilitic states, are, equally with the hot bath, to be 



TREATMENT OF SYPHILIS. 275 

avoided, as in various degrees are apt to induce congestion 
of the nervous centres. In syphilitic patients convulsive 
seizures of a severe grade have been precipitated both in 
the fumigation chamber and in Turkish and Russian 
baths. 

Syphilis of the eye and its appendages is to be treated 
internally on the principles already formulated. Mild 
astringent lotions locally answer well for most of the 
simpler inflammations of the canaliculi and the sac ; in 
rare cases only is division for stricture or the introduc- 
tion of the probang required. When the sclerotic is in- 
volved, instillations of atropia, combined, if there be pain, 
with cocaine, are useful. In iritis of all forms repeated 
applications of hot water slightly impregnated with boric 
acid are to be made over the closed lids, and solutions 
of atropia (from i to 4 grains to the ounce) instilled 
sufficiently often to ensure persistent dilatation of the 
pupil and to tear loose any adhesions between the iris 
and the capsular envelope of the lens. Persistence in 
these efforts is rewarded with success in cases which 
often look desperate, when blood is effused into the 
anterior chamber, and there are apparently unyielding 
attachments of the free border of the iris. Opium for 
relief of pain is rarely required in well-managed cases, 
and is contraindicated by the effect of the drug on the 
pupil ; hence, if it be used in an emergency, the atropia 
must be employed in doses sufficient to counteract fully 
the pupillary action of the narcotic. Leeches may be 
ordered to the temple in plethoric subjects or in case of 
emergency. Mercury is, as a rule, best employed by 
inunction, and the iodide by the mouth. 

Seclusion of the affected eye from the light must be 
secured, and must be continued for some time after relief 



276 SYPHILIS AND THE VENEREAL DISEASES. 

is obtained, in order to avoid recurrence, which is not 
rare. Posterior synechias, as liable to result eventually 
in glaucoma, call for operative interference only when 
persistent. Iridectomy is a last resort in cases which 
by good management should have had a more favorable 
issue. In all affections of the choroid the ciliary muscle 
should be paralyzed wath atropia, and when the optic 
nerve is involved strychnia is indicated. In all bony 
affections of the orbit the iodide is to be pushed to the 
fullest doses tolerable, as in gummatous lesions of the 
liver, brain, and testis. 

Syphilitic lesions of the external ear demand semi- 
liquid unguents containing mercury, carbolic acid, or 
boric acid, applied by means of a toothpick wrapped in 
cotton or on pledgets of lint. Weak mercuric oleate (5 
per cent.) mixed with oil of benne may also be applied. 
In the interest of antisepis, the meatus should be cleansed 
daily with warm borated douches ; vegetations should be 
snipped away with fine scissors, and their bases cauterized 
with the nitrate of silver, care being taken to avoid the 
drum. Too violent treatment is likely to occlude the 
canal by a consequent swelling. When this swelling 
occurs, the walls are to be prevented from adhesion by 
the interposition of pledgets of lint. Warm sublimate 
lotions, I : 10,000, are also valuable when operative treat- 
ment is not demanded. 

In syphilis of the tympanum the naso-pharynx always 
requires attention. Inflation of the Eustachian tube with 
iodinized vapor is in this region distinctly beneficial. 
The constitutional management is of importance, and 
especially the care of the feet, which should be kept dry 
and warm and be dusted nightly with either salicylic 
or boric acid. Suppuration of the middle ear is a grave 



TREATMENT OF SYPHILIS. 2/7 

complication which may terminate fatally ; for details of 
its strictly antiseptic management the reader is referred 
to special text-books on aural disease. Syphilitic involve- 
ment of the labyrinth can be treated only by internal 
medication. 

Hereditary Syphilis. — A woman known to be syphi- 
litic and pregnant should have prompt and energetic 
antisyphilitic treatment, in the interest not only of her- 
self but also of her unborn child. Genital lesions require 
frequent and careful applications with a view to asepsis. 
Warm borated lotions, or solutions of the permanganate 
of potassium, i grain to 2 ounces, should be used — with 
caution, however, when employed as vaginal lotions, 
since a stream of warm water directed against the cervix 
of a pregnant uterus has brought on labor. 

The special treatment of the pregnant woman is by 
mercurial inunctions pushed within the hmits of a 
decided effect upon the gums, and suspended for periods 
during which she is to be subjected to " mixed " treat- 
ment. The mercuric protoiodide, blue pill, and other 
pilular vehicles of the metal are less serviceable than 
the method named. In advanced syphilis the iodide in 
full doses is of unquestioned value and has saved the 
lives of many children. 

In the management of the syphilitic infant at the 
breast the mercurial and other treatment of the mother 
is not to be neglected. Whether the very small amount 
of mercury detected in the milk is of value, or whether 
the improvement which has been noted on the part of 
the child is due to the enrichment of the quality of the 
milk of the mother whose health is benefited by the 
treatment, it is not necessary to determine. In admin- 
istering iodide of potassium to a nursing mother it should 



278 SYPHILIS AND THE VENEREAL DISEASES. 

be remembered that at times the remedy has a very- 
decided influence in inducing suppression of the milk — 
an accident of serious import when a syphihtic child is 
at the breast. 

The direct treatment of the syphilitic infant is a matter 
of the greatest moment. Only upon very strong evi- 
dence should treatment of a syphilitic infant be begun 
before it has betrayed symptoms of inherited disease, 
since, even after the birth of "intensely" syphilitic 
foetuses and a series of abortions, there are brought into 
the world children who never exhibit signs of the disease 
even when both parents have recently been infected. 
This note of warning should be heeded, as some physi- 
cians are ready to pronounce a sickly child syphilitic 
simply because they have knowledge of the venereal 
accidents of one or both parents occurring a brief time 
before pregnancy. 

Seeing that a syphilitic infant does not infect the breast 
of its mother, the child should always, when practi- 
cable, be thus nourished, and should never be suffered 
to take the breast of a sound woman. If breast-milk 
cannot be had, goat's milk may be employed as a sub- 
stitute, or sterilized cow's milk, or cream and warm 
water. A healthy wet-nurse should at all hazards be 
prevented by the physician from exposing herself to the 
dangers of infection. A syphilitic wet-nurse is unfit for 
service. Where the utmost care is requisite in the 
cleanliness of the mouth, nose, anus, vulva, umbilicus, 
etc., the woman who is herself suffering from the acci- 
dents of infection is liable to be a carrier, not of a new 
syphilis, but of the germs of a secondary infection from 
pyogenic cocci. 

When exhibiting snuffles and the exanthemata of 



TREATMENT OF SYPHILIS. 279 

hereditary disease, the child may be given internally 
calomel rubbed up with sugar of milk — from 2V ^^ ro" 
grain to the weak ; to those who are stronger, from \ to 
\ grain three times in the day. The crushed tablet- 
triturates of this salt administered in milk serve a useful 
purpose. An accompanying opiate to relieve diarrhoea, 
advised by some authors, is rarely needed if the dosage 
be adjusted accurately to the requirements of each case. 
Tonics are as necessary for the infant as for the adult 
affected with syphilis. A few drops of a solution of 
citrate of iron and quinine, a drachm to the ounce, may 
be given in syrup ; or Monti's formula : 

^. Ferri lact., gr. v ; 

Hydrarg. chlor. mit,, gr. iss ; 

Sacch. lactis, gr. xxx. — M. 

Ft. chart. No. x. 
Sig. One to be given after taking the breast. 

The gray powder, once highly commended, is un- 
certain, in consequence of its liability to the production 
of the bichloride of mercury. It is given in doses of 
from y^Q- to \ grain, according to the weight of the child. 
We believe these preparations to be preferable to the 
others named below, which should, on the whole, be 
reserved for cases where there is decided intractability 
under the dosage of the mild chloride or the gray 
powder. But the protoiodide is given in combination 
with lactate of iron in doses of from y^^o \ grain rubbed 
up with the sugar of milk ; black oxide of mercury, in 
doses of a similar size ; and corrosive sublimate, in doses 
of from yig to 5V %^^^'^- 

Iodide of potassium in solution may be administered 
to young children in doses of from \ grain to 4 grains. 



28o SYPHILIS AND THE VENEREAL DISEASES. 

This remedy, however, in infants and children is exceed- 
ingly hable to produce a severe grade of medicamentous 
dermatitis and the other accidents of iodism ; further- 
more, it is not so often as in adults productive of bril- 
liant therapeutic effects. It is chiefly indicated when 
there are osseous lesions and those involving the brain, 
the viscera, the testes, the eye, and the ear. The mixed 
treatment advised for adults can often be used, however, 
with advantage in cases where no emergency exists, as, 
for example : 

15^. Hydrarg. biniodid., gr. j ; 

Potass, iodid., 3iij ; 

Syr. simpl., 

Aq. menth. piperit., aa. f^iss. — M. 
Sig. From 3 to 10 drops to be swallowed in large dilu- 
tion, after taking food, three times a day. 

Mercurial inunctions, advised by some authors only 
after the child has attained a certain age and degree of 
strength, we employ with great advantage as soon as 
indicated in the earliest periods of life. It is not the 
method, but the skill directing the method, that renders 
this procedure possible. In very young infants the skin 
is exquisitely sensitive and unable to endure mercurial 
frictions. In such cases the mercurial ointment is com- 
bined with I, 2, or more parts of pure white vaseline, 
and the swathing band is well anointed with the mixture, 
care being observed that the bandage be fastened so that 
it does not turn, and also that one part of it only be 
anointed. In this way the constant motions of the child 
produce a gentle inunction, which may be pushed to any 
desired extent by increasing the quantity of the mer- 
curial in the unguent until a scruple or more is rubbed 



TREATMENT OF SYPHILIS. 28 1 

in daily. During all these applications the child should 
be watched carefully, and on the slightest evidence of 
debility, anaemia, or increased restlessness the remedy 
should be suspended. The same course should be 
pursued when it is observed that the skin over which 
the ointment has been applied is the seat of a mild der- 
matitis ; in which event, if the general condition warrant, 
the inunctions may be practised over another region, 
as over the feet or the shoulders. In point of fact, a 
syphilitic infant furnishes a ready and constant indication 
of the value of the treatment instituted for its relief, in- 
asmuch as its increase in weight, its improvement in 
color, and its capacity for eating and sleeping are 
promptly changed for the better or the worse according 
as such treatment is or is not rightly directed. In the 
event of irritation of the skin being produced in any 
region where a mercurial has been applied, the inunc- 
tions should at once be suspended and the integument 
of that part dusted with a soothing powder such as talc 
or starch, or, in case of need, anointed with freshly made 
benzoinated zinc ointment. 

What good can be wrought by inunction is within 
the range of either mercurial ointment, pure or reduced, 
or the several mercuric oleates. The red precipitate in 
the strength of a i per cent, ointment, the white pre- 
cipitate in the strength of i part to 10 of lanolin or 
vaseline, and mercurial plaster for regions of limited area, 
have all been praised by authors, and may be regarded 
as of value when a change is thought desirable. Hypo- 
dermatic injections and fumigations have been employed 
in hereditary as in acquired syphilis, but no urgent 
reason for their use can be adduced. In the event of 
their selection, the dose should be reduced somewhat 



282 SYPHILIS AND THE VENEREAL DISEASES. 

from that employed in adults, according to the age of 
the child. From i^ to ^Iq grain of the sublimate can be 
injected between the first and fourth years, the smaller 
doses only in the first twelvemonth of life. The subli- 
mate baths recommended by Elsenberg contain about a 
grain of the metal, an equal quantity of the ammonium 
chloride being added, to the gallon of warm water. The 
local applications found useful in acquired syphilis may 
be employed when needed in the case of syphilitic infants. 
The addition of ammoniated mercury, calomel, or yellow 
oxide to the Lassar paste already described, in the 
strength of from 2 to 30 grains to the ounce, will be 
found available in many of the syphilodermata. Tumors 
and nodes should rarely be opened surgically, as they 
can commonly be made to disappear under an appro- 
priate therapy. When the lids are affected, warm borated 
lotions, or those containing the bichloride, I part in 
10,000, may be employed, followed by a weak salve con- 
taining a grain of the yellow oxide of mercury. Atro- 
pine should be instilled, as often as required, both in 
keratitis and in iritis, in the strength of from -^-^ to \ 
grain to the ounce. Leeches may be required over the 
mastoid process to relieve the severe deafness of inherited 
disease, which, if not energetically treated, may result 
in deaf-mutism. No applications are better for the 
special rhinitis of hereditary syphilis than those contain- 
ing nitrate of silver, from \ to I grain to the ounce 
being injected or wiped over the surface, and followed 
by an albolene spray. In some cases this spray answers 
well, employed alone or after the addition to it of a few 
drops of carbolic acid and a single drop each of the 
tincture of iodine and glycerin. The mouth should be 
cleansed thoroughly and repeatedly with solutions of 



ACQUIRED INFANTILE SYPHILIS. 283 

boric acid and honey, usually best applied by dipping in 
the solution a soft rag or a handkerchief which is wound 
about the finger of the nurse and then applied to every 
part of the child's mouth. The anus should be kept 
scrupulously clean, and should frequently be dusted with 
boric acid or boric acid and talc in equal parts ; if 
condylomata form, these should be deodorized with 
liquor sodae chlorinatae, and after drying should be 
dusted with calomel and talc, i part of the former to 4 
parts of the latter. Mercurial plasters are useful appli- 
cations to tumors and swellings over bone, digit, joint, 
or muscle, and can also be wrapped neatly about an 
involved testis. 

Acquired Infantile Syphilis. 

The acquired syphilis of infants differs from the in- 
herited form chiefly in the important particulars that its 
evolution is on the lines observed by the acquired 
disease, and that the patient does not start life with 
lesions of the viscera, of the bones, or of other important 
organs. As a rule, under proper care the issue in these 
cases is fairly favorable. The acquired syphilis of infancy 
is chiefly remarkable for its display of moist and secret- 
ing lesions and for its failure to relapse in cycles as does 
acquired disease of adults. The first-named feature is 
due to the soft character of the infant's tissues ; the last- 
named, to the constant control to which the child is 
subjected when the disease is duly recognized and prop- 
erly cared for. But in unrecognized or neglected 
acquired syphilis of infancy the results may be as mu- 
tilating and as disfiguring as in the worst phases of 
acquired disease of later years. 



284 SYPHILIS AND THE VENEREAL DISEASES. 



SYPHILIS IN RELATION WITH THE FAMILY 
AND SOCIETY. 

It is obvious that if every infected individual were 
restrained from communicating syphilis to another, the 
extension of the disease would speedily be checked. 
Unfortunately, the barriers to such an advance in the 
improvement of the public health seem at present to be 
insuperable. The duty of the physician, however, is 
none the less clear and urgent. The victim of the 
disease should be impressed with the fact that he is a 
possible source of danger for the uninfected, and should 
be shown the methods by which he is to protect those 
with whom he must necessarily come in contact. To 
the father of a family and to the unmarried of both 
sexes it is, in general, proper to state the nature of the 
disease recognized, if this be unknown before the date 
of consultation, and also to point out the danger of 
transmission and the methods by which such accident 
may be prevented. In the presence of a syphilitic wife 
ignorant of her condition the physician is placed in a 
position of peculiar delicacy. As a rule, these innocent 
victims of the disease have been infected by a guilty 
husband. The physician then discharges his task if he 
insists upon a personal interview with the master of the 
household, declaring the facts to the latter and insisting 
upon the need of informing his partner at once of the 
nature of the disorder, that she may take such measures 
as will ensure her safety. In such cases it is plainly the 
office of the husband rather than of the physician to 
perform this disagreeable duty. An infected wife sep- 
arated from her husband by death, divorce, or mutual 



SYPHILIS AND THE FAMILY. 285 

arrangement should, as a rule, learn the truth directly 
from her physician. It is her right to understand the 
nature of her disorder, that in any emergency she may 
have a clue to the treatment which may then be de- 
manded urgently. Women have actually lost their lives 
in consequence of ignorance on this point. Before, how- 
ever, any communications of this sort are made by the 
physician to the patient, the former should be absolutely 
certain of the correctness of the diagnosis. As the 
peace of a family is often at stake, an error here is 
unpardonable. In any case of doubt further advice 
should be sought. 

If the husband or the wife be infected from an extra- 
marital source, it is the obvious duty of the diseased to 
inform the sound partner of the fact, that he or she may 
take precautions sufficient to ensure safety. Here, too, 
it is plainly the duty of the guilty to inform the innocent, 
and the physician has a right to insist upon the perform- 
ance of this duty, to save not merely the uninfected, but 
also his own personal reputation. Otherwise, when the 
facts are eventually discovered (and they usually are) he 
may be held to have been a party to a plot to conceal 
the truth to the damage of the infected. If there be a 
positive refusal of the patient to discharge this duty, 
there are two ways in which the physician may proceed : 
One is that suggested by Fournier : The physician may 
send a written letter to the guilty party, insisting upon 
the need of telling the truth, and retain a copy of 
this letter for later justification. The other way is 
for the physician to decline further connection with the 
case. 

As a matter of fact, in the great majority of all cases 
the infected consort cohabiting with the non-infected 



286 SYPHILIS AND THE VENEREAL DISEASES. 

person who is ignorant of the facts sooner or later trans- 
mits the disease, notwithstanding all protestations and 
precautions. As a matter of fact also, the " confessed " 
cases are those where transmission almost never occurs. 
There is sufficient popular dread of the disease to ensure 
the forewarned against the incurrence of risk. Excep- 
tions may possibly be made in the instance of long 
separation of husband and wife, or of long-continued 
illness of either, rendering the performance of the sexual 
act impossible or remotely improbable ; and also in cases 
where each of the married couple habitually occupies a 
separate chamber and bed. In some of these cases the 
temptation to indulge in the sexual act, from a sudden 
and scarcely resisted impulse, at a time when objective 
symptoms of the malady seem to be for the moment re- 
moved, is to a large extent set aside. 

It is a remarkable evidence of the tenacity with which 
the marriage tie unites even those who have disregarded 
its sacredness, that but a small proportion of the men 
who confess to their wives their fall and their infection 
by that fact alone break up their families. It is an 
offence against a woman, usually unpardoned, if her 
husband, after violating his marriage vow, afterward in- 
flicts upon her a venereal disorder through a cowardly 
dread of confessing the truth. The courts fully recog- 
nize this, and give her, when she asks it, speedy and 
just redress. In daily practice, however, a man who, 
unfaithful to his wife, has been, as a consequence, in- 
fected, and who confesses to her his story rather than 
contaminate her in his embrace, usually wins her sym- 
pathy and often retains her love. She respects his 
courage, and if, as often proves to be the case, the hus- 
band has committed his offence when under the influence 



SYPHILIS AND THE FAMILY. 287 

of alcoholic stimulants, she often forgives. The con- 
scientious physician cannot be too strongly urged to 
conserve the health and the peace of families threatened 
by the advent of an infectious disease by exerting all his 
influence in the direction of securing a confession to the 
wife by the husband, who in the great majority of all 
cases is the one at fault. 

It need not here be set down that the unmarried in- 
fected with syphilis should not indulge in the sexual act. 
When under an engagement to marry at the date of in- 
fection, both parties to the contract should earnestly be 
advised to cancel the engagement. In the intimacy 
between two such persons made possible in most classes 
of society, a kiss upon the lips has often served to trans- 
mit the disease, and to convert an affectionate regard 
into a feeling of detestation and horror. For most of 
these people a period of three years at the least is likely 
to elapse before the physician can consent to a union, 
and it is unjust to expect a young woman to bind her- 
self for that period to any man capable of acquiring 
syphilis by the usual methods of its transmission. The 
course which will in the end save the most mental and 
physical misery for both persons, and which will in the 
future furnish the least anxiety to the physician, is dis- 
ruption of the bond. 

With respect to the marriage of the veteran of syphilis 
the decision may be different. There is no time in the 
life of the infected when, for any reasons known to 
science, it may positively be affirmed, without possi- 
bility of disproof, that he or she can become the pro- 
genitor of healthy children and not infect a partner in 
marriage. This is, in effect, a proposition that the in- 
fected should never marry; and, as thousands of men 



\ 



288 SYPHILIS AND THE VENEREAL DISEASES. 

annually do marry and have sound children and never 
transmit syphilis to their wives, it follows that there must 
be some rule which, if not absolutely safe, will furnish 
in its application a maximum of practical and satisfactory 
results. 

It is wholly unfair, when considering the question of 
marriage from the point of view of medical science, to 
set the patient who has made a satisfactory progress to- 
ward the termination of syphilis in a category apart from 
the tuberculous, from those having a record of recur- 
ring insanity in their family histories, and from those 
affected with infirmities tolerably certain to terminate 
life within a brief period of time. All these classes 
annually marry and intermarry, with disastrous results 
to themselves and to society. The veterans of syphilis 
make a far better statistical showing. 

It is impossible to lay down rules for all cases, but the 
following limits are fairly well established in practice : 
A previously healthy young man or woman, skilfully 
treated for between three and four years after infection, 
and free for the last year from any but the most insig- 
nificant symptoms, will in the large majority of cases fail 
to infect a married partner or transmit syphilis by in- 
heritance. 

No man should marry, whatever time may have 
elapsed after infection, who has not had a long interval 
— at the very least six months — of absolute freedom from 
symptoms ; and the reverse is true, that no man should 
marry, however remote the date of his infection, who 
bears upon his person active symptoms of his disease. 
There are subjects of syphilis who should never marry, 
though these are few. In them the disease has induced 
a cachexia permitting an evolution of the malady to the 



SYPHILIS AND THE FAMILY. 289 

point where the systemic infection is too profound and 
too persistent to permit a return to a normal standard of 
health. 

When syphilis has actually been transmitted from 
husband to wife, or the reverse, and the two, after a 
reasonable abstinence, again cohabit, a problem of some 
gravity is presented to the physician. As a rule, sexual 
indulgence between such consorts should be postponed 
to the utmost limit, seeing that in case of offspring 
the chances of inheritance of the parental disease are 
doubled by reason of the infection of both father and 
mother. Even here, so provident is nature for its well- 
being, the child may completely escape ; but the peril is 
very great. In this case husband and wife should be 
conjured to take every precaution against the occurrence 
of pregnancy; and the only safe and justifiable precau- 
tion is total abstinence from sexual indulgence. Nor is 
this conscientious denial of the bodily appetites the 
Utopian dream of a social reform for the future. Every 
physician of experience has had, knowledge of husbands 
and wives who, impelled by a high sense of duty to 
themselves, to their families, and to the world, have lived 
for years in asexual companionship, waiting for the time 
when their physical union would not be shadowed by 
the possibility of bringing a reproach upon themselves 
and a curse upon their offspring. 

With respect to the question, frequently raised, as to 
the insurability of the infected in life-assurance societies, 
the companies who accept risks in the United States are 
not as yet agreed in their practice. The physician, how- 
ever, who examines the applicant can, when the exact 
facts of the syphilitic history are obtained, make a 
reasonable forecast of the longevity prospects. With a 

19 



290 SYPHILIS AND THE VENEREAL DISEASES. 

history of mild syphilis, and one terminating without 
appreciable results six months or a year before the date 
of the examination, the forecast is decidedly good. 
There is not here a question as to the danger of trans- 
mission of the disease, but solely one of longevity. The 
longevity prospects of the average of the infected are 
better than the companies themselves probably believe. 
The number of the infected subsequently dying of 
tuberculosis or of carcinoma is exceedingly small ; and 
this immunity, as the later acquisitions of science sug- 
gest, is related to the inevitable war waged between 
pathogenic micro-organisms. With evidences of a 
recent or grave syphilis the examiner may well be 
cautious ; but even here there is little prospect that 
life will be shortened save by the occurrence of some 
of the nervous complications of the disease. 

The regulation of public prostitution by law with a 
view to the extermination of syphilis has long been 
practised in France, Belgium, and other countries, either 
generally or with defined limitations. This regulation 
has for the most part included surveillance and peri- 
odical examination of the persons of public women, with 
segregation of all the infected by the aid of enforced 
hospitalism. The results have been, from a scientific 
point of view, in a high degree unsatisfactory. It is a 
significant fact that the country that has longest regu- 
lated prostitution by law has also furnished the most 
voluminous literature, and until a recent period the most 
authoritative writers, on the subject of syphilis. The 
scheme of sanctioning prostitution in any way has 
always been repugnant to the commonwealths inheriting 
the traditions of the Anglo-Saxon race, and, now that 
such sanction is recognized as practically valueless, it is 



SYPHILIS AND SOCIETY. 29 1 

in the highest degree improbable that the United States 
will ever, in the effort to solve this problem, imitate the 
practice of the Old World. 

The proper view of this question, as of most of the 
questions connected with the sexual relation, must surely 
include both men and women. The law which demands 
a periodical examination of the female should also require 
a periodical examination of the male prostitute. Every 
expert to-day recognizes the fact that the syphilitic male 
is as liable to disseminate his disease as his companion of 
the other sex. If one must exhibit a certificate of health 
before sexual congress is permitted, so should the other. 
If one, in order to escape the penalties of the law, is to 
secure an official license, so should the other. In these 
closing years of the nineteenth century, when women 
of the highest character and intelligence are interesting 
themselves in this subject, no sensible person can doubt 
that if any regulation whatever be ordered, it will, assur- 
edly in America, bear equally upon both sexes. 

But, all said and done, the representatives of advance 
in social science should clearly recognize the fact that 
syphilis is not, as has been claimed by a class of 
hysterical writers in many lands, a scourge threatening, 
above all other maladies, the devastation of the human 
family. Tuberculosis annually destroys many more vic- 
tims. It would not be unjust to demand that the State 
shall ensure the fullest security to life for the residents of 
large cities, in the way of provision for pure water, milk, 
ice, food, and freedom from accidents, before it attempts 
to police the houses that are visited only by those leading 
immoral lives. The proportion of syphilitic to other 
diseases in no part of the world exceeds a variation of 
between 2 and 5 per cent, when both sexes are estimated 



292 SYPHILIS AND THE VENEREAL DISEASES. 

in the statistical returns. Most of the pubHshed tables, 
unfortunately, include figures obtained from army and 
navy hospitals, where men only are sheltered. 

The great safeguard against syphilis is sexual m^orality, 
without which no safeguards are worthy of the name. 
It is held by writers that for young men this is too lofty 
an ideal ; but such objectors have no practical knowledge 
of the moral standard upheld by many of the wisest 
thinkers and realized by thousands of self-denying youths 
in every community. The physician who does not exert 
his influence in the interest of this standard, by which 
men and women alike not merely protect themselves 
from these maladies, but ensure also the safety of the 
community in which they live, has yet to learn the 
alphabet of sound health. 



CHANCROID. 



Synonyms. — Soft chancre ; Simple chancre ; Non- 
infecting chancre ; Fr. Chancre mou ; Chancrelle (Diday) ; 
Ger. Einfacher Schanker ; Weicher Schanker. 

Chancroid is a contagious venereal disease character- 
ized by the occurrence, chiefly in the genital region, of 
one or more, often several, suppurating and ulcerative 
lesions, due to the presence of micro-organisms, and not 
ultimately productive of specific constitutional symp- 
toms. The secretions of a chancroid lesion, when 
unmingled with those of syphilis, are never succeeded 
by the symptoms of the last-named disease. It is, how- 
ever, to be noted that both the virus of syphilis and 
that of chancroid may be implanted at one moment 
upon the same susceptible point, and from such a point 
the phenomena of the two diseases may afterward be 
evolved. 

The establishment of an absolute distinction between 
chancroid and syphilis has been reserved for tlie latter 
half of the present century. For a long time after the 
distinctive differences between the two affections were 
recognized and classified, the scientific world discussed 
with energy the questions respecting " the unicity or 
duality of the chancrous virus." No one, however, at 
present holds that there is a duality of the syphilitic 
virus or of chancre. The unicity of each, to employ an 
outworn phrase, is unquestioned. But it is certain that 

293 



294 SYPHILIS AND THE VENEREAL DISEASES. 

there is a contagious venereal disease, local in its effects, 
communicable at the same time with syphilis, the feat- 
ures of which may be confused with those of the initial 
sclerosis of that disease. 

To demonstrate without possibility of error that an 
individual may be the subject of even a grave ulcerative 
lesion which is never followed by syphilis, incurred in 
sexual exposure of the genital region, may be named 
as one of the achievements of modern science; but a 
grievous price has been paid for this knowledge in the 
errors which have resulted on the part of both phy- 
sician and patient. Thousands of initial scleroses of 
syphilis are annually mistaken for chancroids ; and even 
the onset of unmistakable signs of systemic syphilis, 
after such blunders have been committed, has been for 
a time ignored or misconstrued. The false security 
engendered by over-confidence, ignorance, and folly 
furnishes the background for a historical warning which 
no man can afford to ignore. It is well, at the very 
outset of a study of soft, non-infecting chancres, or 
chancroids, to realize the great danger of confusing them 
with the initial scleroses of a disease whose impress 
may last for a half-century, and whose symptoms may 
actually be intermingled with the most classically devel- 
oped of chancroid ulcers. 

Etiology. — There is little doubt in the mind of any 
modern observer as to the existence of a specific micro- 
organism which is the effective agent in the production 
of the chancroidal ulcer. At the present writing the 
identification and the recognition of the etiological value 
of such a micro-organism are not established. The proof 
of existence of such a germ rests practically upon the 
same basis as that generally assumed for the agent effect- 



CHANCROID. 295 

tive in the production of syphilis. That the discovery 
of the one will throw a flood of light upon the etiological 
importance of the other cannot be doubted. 

At the present time, however, there are not wanting 
those who assert that the effective micro-organisms of 
chancroid are simply the staphylococci and the strepto- 
cocci which are concerned in the production of pus in 
general. In support of this view it is claimed that the 
peculiarities of the chancroid are due chiefly to the 
anatomico-physiological characters of the soil in which 
it chiefly thrives — namely, that of the ano-genital region 
of the cachectic and the filthy ; that the recognized pus- 
organisms are found in all cases of chancroid ; that, in 
spite of exhaustive bacteriological research, no other 
organisms have yet been demonstrated as capable of 
producing the disease ; that the results of inoculation 
of the skin of the ano-genital region with simple pus 
are not distinguishable from chancroid; and that the 
secretion of such artificial lesions is capable, like that 
from the chancroid, of repeated auto-inoculation. 

But, per contra, it is to be noted that chancroids at 
times occur in those who are neither filthy nor cachectic, 
and that the worst results may be exhibited in individuals 
of a healthy class ; further, that while inoculations of 
simple pus (for example, that from an acne pustule) have 
produced lesions scarcely distinguishable from those of 
chancroid, yet that pus even from these sources is by no 
means always of the " simple " character claimed, since 
tubercle bacilli and other micro-organisms little sus- 
pected as present have been distinguished in pus taken 
from supposedly innocuous sources. 

The clinical argument against the position described 
above is very strong. A periurethral phlegmon may 



296 SYPHILIS AND THE VENEREAL DISEASES. 

burst through the integument of the penis ; an abscess 
of the vulvo-vaginal gland comphcating a gonorrhoea 
in women may open through the vaginal wall near the 
vulvar orifice ; a large pustule of the skin of the penis 
may be produced by the presence of the acarus scabiei ; 
a suppurating balanitis in phimosis complicated by a 
tight stenosis of the preputial orifice may result in the 
practical imprisonment of an exceedingly foul purulent 
product ; and in uncomplicated cases, neither in any of 
these nor in similar accidents of the same region that 
might be cited will there be the slightest approach to 
the formation of a chancroid. Such an occurrence, if 
well authenticated, would at once revolutionize all the 
accepted doctrines in this field ; and, to push the pos- 
sibilities no further, were simple pus sufficient to induce 
a chancroid in a filthy and cachectic subject, the sur- 
geons of ships' crews, at a distance both in time and 
space from port, their sick afflicted with scurvy and 
attacked with vermin, might expect an outbreak of 
lesions which, as a matter of fact, are never seen except 
when sailors have been recently in contact with public 
women in some haven of entry. 

The number of observers claiming to have identified 
the micro-organism of soft chancre is large. At the 
beginning of the list are the names of Salisbury and 
Didier, and these names are followed by those of Luca, 
Ducrey, Welander, Krefting, Strauss, JuUien, and Unna. 
Most of the later authors have busied themselves with 
the micro-organism of Ducrey, a short and thick bacil- 
lus with rounded extremities, occurring in groups and 
chains between and in the bodies of the cells themselves. 
It is readily stained with alcoholic solutions of fuchsine, 
methyl-violet, and gentian-violet. Krefting used as a 



S\'1M1ILIS. 



I'LAIK 7. 





# 






\>C 






%^^: 









''\J* 



I. Hutchinson's teeth. 2. Bacilhis of Ducrey (Petrini de Galatz). 



CHANCROID. 297 

Staining solution 16 grams of a 5 per cent, borax solu- 
tion, 20 grams of a saturated aqueous solution of methyl- 
violet, and 24 grams of distilled water. Streptococci and 
staphylococci were found in the first generation only 
of cultures, rarely in the fifth or the sixth. In all cases 
the streptobacillus of Ducrey was recognized by these 
observers, with the exception of JuUien and Strauss, 
who were unable to discover it in their examinations. 
The determination of the problem is for the time being 
relegated to further investigation. 

The Lesions of Chancroid. — The clinical symptoms 
of chancroid depend largely upon accidental circum- 
stances, the important factors being, first, contact with 
neighboring parts (friction, maceration, etc.), and second, 
the site of infection. The typical chancroid develops 
where the site is such that the lesion can progress 
symmetrically and at the same time be uninjured by 
traumatism. With these conditions fulfilled (as after 
intentional inoculation) the earliest symptom is the pro- 
duction of — 

TJie Pustular Lesion. — This lesion develops at the site 
of infection, first as a minute hyperaemic macule which 
is evolved in twenty-four hours after inoculation, a pin- 
point-sized vesico-pustule appearing within forty-eight 
hours after and being surrounded by a reddish halo. 
Day after day, progressively, this lesion, when protected, 
enlarges and changes to a pustule of the type once 
described as " ecthymatous," attaining the size of a small 
coin. 

When the roof-wall of this pustule is broken and its 
purulent contents are carefully removed by wiping, the 
floor of the original chamber may be recognized as an 
ulcer, corresponding in circular outline and dimensions 



298 SYPHILIS AND THE VENEREAL DISEASES. 

with the original pustule. The floor of this ulcer is 
covered at first with a pultaceous and sloughy deposit ; 
later, as repair ensues, it assumes at first a violaceous 
and velvety aspect, and still later presents the features 
of a healthy granulating surface. The circular walls 
are steep and abrupt, as if produced by a sharp punch. 
The base in uncomplicated cases is invariably soft 
and supple, never in the least suggesting the stony 
hardness of a typical sclerosis of syphilis. There is 
usually a more or less angry-looking areola spreading 
to a variable distance away from the centre. The sup- 
puration, at first abundant, becomes decidedly more 
scanty as the stage of repair approaches. In general, 
the condition is one of inflammation accompanied by 
more or less soreness and pain of the part. In this 
respect also the lesion differs from the commonly pain- 
less induration of certain scleroses of syphilis. 

Tlie Erosive Lesion. — Here the modification results 
from the early removal of the roof-wall of the pustule 
by an accident (softening by maceration with mucus, 
friction of contiguous parts, etc.), or from infection of 
a site where, for any reason, the pus produced does not 
become chambered. At such points there is infection 
of an open surface, such as the mouth of a follicle, the 
site of a ruptured herpetic vesicle, or the seat of a slight 
trauma (about the verge of the over-stretched anus, 
over a torn fraenum, etc.). In these cases the lesion 
is ab initio a suppurating ulcer. Its contour is rounded, 
oval, or conforms to the accidents of site to be named 
later. The pus is thick, creamy-yellow in hue, and 
when removed discloses an empurpled floor or one 
covered with the peculiar wash-leather-like slough, re- 
sembling nothing so nearly as the floor of a typical 



CHANCROID. 299 

gumma after bursting. Occasionally these sores, after 
exhibition of " open " symptoms, cover themselves with 
an adherent crust which increases in size as the ulcer 
spreads beneath, so that lesions as large as a silver 
dollar and even larger may thus be formed. The cha- 
racter of some of these developing and crusted chan- 
croids may be misapprehended by both patient and 
inexpert physician, who may be applying unguents, 
powders, or other dressings to the outer surface of a 
large crust of this character. The removal, however, 
of such a crust may disclose an abscess as large as the 
section of a hen's ^%%, with characteristic chancroidal 
ulcer for the floor. 

Variations of chancroid are from each of the types 
described above. The shape, for example, may be altered 
greatly by the infection of a wound or of a point situ- 
ated between two abruptly elevated mucous sufaces. 
In the former event the lesion may be linear (chancroid 
of the anus or fraenum) or dumb-bell-shaped (as when 
the sore begins in the sulcus back of the corona glandis 
of the penis and spreads in a double circle over the 
prepuce and glans). 

Number. — The chancroid may be single ; but it is 
usually multiple, and this multiplication may be enor- 
mous. Usually no more than from four to six lesions 
are seen at one time upon a single individual ; but in 
exceptional cases hundreds may be counted, as when, in 
women, the secretion from a few lesions on the upper 
portion of the vulva flows over not only the lower 
portion but the entire perineum and anus. 

Multiplicity in the number of chancroids depends 
chiefly upon auto-inoculability of the secretion. The se- 
cretion of the initial sclerosis of syphilis is non-auto- 



300 SYPHILIS AND THE VENEREAL DISEASES. 

inoculable save in those cases where there is mixed in- 
fection (with chancroid), or irritation of the lesion by 
accidental agencies, causing suppuration. The abun- 
dant pus of the chancroid, however, furnishes the amplest 
material for ensuring multiplicity of lesions, not merely 
(as constantly happens) at the moment of infection, but 
also after infection, to the point of production of two 
or more chancroids which proceed promptly to multiply 
when contact with adjacent parts is not prevented. 

Size. — The majority of chancroids do not exceed in 
size the section of a large bean ; but great variation 
exists between the extremes of the minute, pin-point- 
sized lesions, scarcely attaining average dimensions, and 
the largest ulcers, which may considerably exceed in 
size a platter, covering, for example, a broad area of the 
skin of the belly and spreading downward over the 
inner face of the thigh. 

Duration. — The persistency with which a chancroid, 
even after extensive and thorough cauterization, unfail- 
ingly pursues its career of evolution and involution is 
one of its distinguishing features. It outlives, as a rule, 
all the tissue-destruction produced by an ordinary 
abscess of the region where it occurs, and in one form 
or another it commonly consumes a definite time before 
its last traces are removed. From three to six weeks 
may be said to be the average duration of a simple and 
wholly uncomplicated case. All the complications of the 
disease, however, may prolong its term. 

The chronic ulcers occurring chiefly about the genital 
region of the lower class of prostitutes, but seen also in 
men, persisting for many months and even for years, 
belong to a special category which will be described 
later. Here the unusual duration of the disease is due, 



CHANCROID. 301 

not to any inherent tendency of the affection to prolong 
itself indefinitely, but to accidents of the process. 

Incubation. — Properly speaking, there is no period 
of incubation for the chancroid. As a rule, by exceed- 
ingly careful observation with a lens the infectious pro- 
cess is made evident within a few hours, twenty-four at 
most, after the introduction of the virus. In the average 
of loosely observed clinical cases patients declare that 
their infection became evident a few days after exposure. 
It is rare that chancroids appear later than the tenth 
day after infection. 

Cases, however, are not wanting where the first symp- 
toms of the disease become apparent two or three weeks 
after contact. In this event it is generally believed that 
the virus was simply deposited on the surface, not en- 
countering a follicle whereby access was obtained to the 
deeper tissues, and that later by its presence the virulent 
secretion excited an irritation which eventually opened 
up a portal to the lymphatic system. The ease, how- 
ever, with which chancroids reproduce themselves after 
mere contact should throw discredit upon such an 
hypothesis. 

By far the most acceptable explanation of apparently 
long "incubative" periods is the ignorance of the patient, 
for these periods of time, of the existence of the disorder. 
Incredible though it may appear, there are few experts 
who, after recognizing threatening inguinal adenopathy, 
are not guided by this condition to exploration of the 
genital region, with the result of discovering and first 
pointing out to the patient a previously unsuspected 
chancroid. Often a minute, pin-point-sized lesion is 
thus found lurking in one of the pockets by the side 
of the fraenum, or hidden immediately behind it, or in 



302 SYPHILIS AND THE VENEREAL DISEASES. 

another unobtrusive region. It should be remembered 
in this connection that many, but by no means all, of the 
patients displaying these symptoms are of the filthy 
class, with associates of similar social grade. In men 
of this type it is not rare to discover a remarkable 
toleration of the uneasiness produced by a long-con- 
tinued accumulation of the smegma praeputii, and the 
sensations produced by chancroids are mistaken by 
such patients for the pruritic symptoms induced by the 
mild balanitis which retention of the smegma often 
excites. 

Subjective Sensations. — From what precedes it will 
be seen that the chancroid, as distinguished from an 
infecting sclerosis, may be the source of subjective 
symptoms. These symptoms may be merely pruritic 
or may be of the grade of severe pain. Exceptions in 
this particular are noteworthy. At times the infecting 
chancre of syphilis is painful and the chancroid is unpro- 
ductive of sensations of a morbid character; but for 
the majority of cases the chancroid is distinguished by 
its inflammatory character and by the tenderness and 
pain associated with it. These symptoms are more 
pronounced when the lesion is rapidly progressing as an 
ulcer, or when — a rare accident in modern practice — 
there are complicating accidents of the order of gangrene 
or phagedena. 

Absence of Specific Induration. — The base of the 
typical chancroid, however large-sized and deeply ulcer- 
ated, is invariably pliable, softish, and non-indurated. 
It never exhibits, save in mixed forms, the characteristic 
ivory-like hardness and density of an equally typical 
initial sore of syphilis. There may be inflammiatory 
engorgement, and, after extensive cauterization, a marked 



CHANCROID. 303 

thickening of the tissues on which the ulcer rests, but a 
truly characteristic hardness is never produced by these 
means. 

While this is true, the fact remains that only a skilled 
touch, and even that in doubtful cases only after repeated 
examination, can decide accurately upon the nature of 
the disease. It is not a wholly safe procedure to base 
a decision as to the character of a venereal sore upon 
the test of its induration at a given moment under the 
finger and thumb of an expert. There is a decided 
difference between a voluminous mass of infiltration at 
the base of a simple chancre which has been inflamed 
by any of the accidents to which it has been exposed, 
and the exceedingly delicate, parchment-like induration 
of the syphilitic chancre in some of its least pretentious 
types. In brief, upon the presence or absence at any 
one moment of induration, or what seems to be indura- 
tion, an exact diagnosis cannot invariably be based. 

Auto-inoculability of the Secretion. — The purulent 
secretion furnished by a typical chancroid is indefinitely 
auto-inoculable on the person of the affected individual 
— a fact repeatedly demonstrated by the occurrence 
clinically of lesions in regions in close proximity to 
chancroids. Thus, a sore situated on one labium is 
tolerably sure to infect a corresponding point on the 
other side; a chancroid upon the outer face of the 
scrotum, the portion of the thigh naturally in close 
contact. In this way it happens that in cases scores 
and even hundreds of chancroids are found in filthy 
and neglected subjects where the indefinite auto-inocula- 
bility of the sores has been in no way inhibited. That the 
pus-corpuscles are chiefly responsible for this virulence 
would be suspected on a priori grounds, even had it not 



304 SYPHILIS AND THE VENEREAL DISEASES. 

been demonstrated that the secretion, when deprived of 
its pus-cells by filtration, is either non-inoculable or 
produces, when any results at all are obtained, an 
atypical lesion. 

In this connection it is needless to do more than set 
down the fact that in the early part of the last half 
of the present century the practice of so-called *' syph- 
ilization," enthusiastically lauded in Sweden, was based 
on an erroneous interpretation of the auto-inoculability 
of the chancroid. By practically exhausting the power 
of the skin to react against a great number of artificial 
inoculations with chancroidal pus it was thought that 
syphilis was eradicated. The doctrines then held have 
long since been abandoned, and the practice has properly 
been relegated to a place among the curiosities of 
medicine. 

Location. — Chancroids are said to occur, like the 
initial scleroses of syphilis, upon any portion of the 
integument and the adjacent mucous surfaces; but such 
statements cannot be accepted without reserve. Cer- 
tainly there is no proportion whatever between the fre- 
quency of extra-genital infecting scleroses and chan- 
croids, the former being in large centres of population 
scarcely a curiosity, and the latter being one of the 
rarest of all experiences. The most frequent site of 
chancroids is, with overwhelming preponderance, the 
genital region ; and the aphorism still holds, that 
chancroid is the most truly venereal of all the diseases 
classed under that title. 

In men the most frequent sites of chancroids are the 
fraenum, the prepuce, the glans, the sheath of the penis, 
and the tip of the urethra. In the last-named region, 
however, infecting chancres are much more common. In 



I 



CHANCROID. 305 

women the sites of common occurrence of chancroids 
are the labia majora and minora, the vestibule, and the 
mucous membrane of the vagina near the ostium. Anal 
and perianal chancroids are far more common in women 
than in men, by reason of the readiness with which the 
auto-inoculable secretion flows over the perineum to 
the sensitive and readily eroded mucous orifice of the 
anus. 

Extra-genital chancroids are chiefly found upon the 
mouth, the eyelids, the lips, and other parts of the face. 
They are among the rarest of all venereal lesions. 

Complications. — Mixed Chancre. — The subject of 
chancroid may exhibit, in the course of a few days after 
exposure, several typical lesions the result of simulta- 
neous infection or consecutive auto-inoculation. All these 
lesions, in the course of a fortnight, may be progressing 
toward complete involution, when one of them (rarely 
more) may begin to assume the characteristics of an initial 
sclerosis of syphilis, general symptoms of the disease 
following in due course. These cases are illustrations 
of coincident infection with the virus of the soft chancre 
and of syphilis, the resulting sore being of the type 
commonly termed " mixed." Here two diseases coexist, 
precisely as when patients of the lower class present 
themselves at the public charities, suffering at the same 
moment from local evidences of syphilis, blennorrhagia, 
and infection of the skin or of the mucous membranes 
with pyogenic cocci. For details of the mixed chancre 
the reader is referred to the pages of this work devoted 
to the subject of syphilis. 

Vegetations and other Lesions of the Skin a7td the 
Mucous Membranes. — Venereal warts, herpetic vesicles 
or patches of membrane affected with balanitis and pos- 
20 



306 SYPHILIS AND THE VENEREAL DISEASES. 

thitis may coexist with chancroids, and at times disguise 
their features to a marked extent. 

PJiimosis and Paraphimosis. — These affections are 
frequent compHcations of chancroid, and when of severe 
grade often produce excessive pain and distress ; but 
the results are, however threatening, commonly not seri- 
ous. In some cases one or several chancroids are im- 
prisoned beneath an irreducible, enormously swollen, 
purplish-hued prepuce, its orifice discharging a foul and 
purulent fluid which may by auto-inoculation serve to 
identify the character of the imprisoned lesions, inacces- 
sible save after operative interference. There are often 
one or two small, tell-tale chancroids on the verge of the 
preputial orifice, indicating the character of the lesions 
within the pouch. At times the distress is so great that 
the glands in the vicinity enlarge by sympathy. The 
** mixed" chancre in this situation speedily betrays itself 
by a sclerosis which may often be detected with the thumb 
and finger through the tissue of the oedematous and em- 
purpled prepuce. Often, too, in public practice these 
conditions are complicated with gonorrhoea, the pus of 
which escapes, with that from the sores, through the 
stenosed preputial orifice. Sloughing may ensue in 
unrelieved cases, but it is an exceedingly rare result, 
and need never be feared in any properly treated cleanly 
patient. In a severe type of complicated disease the 
glans penis pushes its way through the sloughing upper 
limb of the foreskin, whose tumid and dependent lower 
limb presents the odd appearance of a second glans at 
the extremity of the penile organ. 

In paraphimosis the result is different, though the 
tumefaction may be fully as great, and the destructive 
action in grave cases may be as formidable. In severe 



r 



CHANCROID. 307 

phimosis the Hne of ulceration, forming in an effort to 
reheve the tension, spreads at right angles to the shaft 
of the penis, in the sulcus behind the proximal roll of 
oedematous tissue. When chancroids are present, it is 
rarely the case that this line of ulceration, intended to 
afford relief, does not suffer infection. In serious states 
the ulceration spreads upward over the integument of 
the organ, fusing several of the chancroids present into 
a single gigantic ulcer. The " subpreputial frill " of 
writers is the lower limb of an cedematous prepuce, in 
these cases often retracted and beset with chancroidal 
ulcers. 

Phagedena. — This complication may coincide with or 
be succeeded by sloughing and gangrene — accidents 
exceedingly rare in the evolution of the initial scleroses 
of syphilis, and, as a matter of fact, in the practice of 
modern medicine- rare even in chancroids. When 
phagedena occurs, however, it is a serious disorder and 
is usually difficult to manage. 

In these cases the result may be due to improper 
local or general treatment (violent cauterization; subjec- 
tion of the patient to the action of mercury, under the 
impression that the disease is syphilitic in nature, etc.), 
filth, cachexia, struma, and the other causes of local or 
general deterioration of vigor. There may be extension 
of the ulcer in one or in all directions by a serpiginous 
process wherein the disease spreads by virtue of its 
auto-inoculable virus, and at the same time destroys the 
tissue in its path. This may be a superficial or deeply 
spreading process ; it may be relatively rapid or, what is 
more common, exceeding slow and painful, scarcely 
giving rise to much distress. As the disease spreads 
in one direction it may heal in another ; or it may result 



308 SYPHILIS AND THE VENEREAL DISEASES. 

in the production of a large area of ulceration, with 
uneven and irregular floor covered by a sloughy, pulta- 
ceous, and adherent mass ; softish base ; scanty or semi- 
purulent secretion; abruptly steep, occasionally under- 
mined, edges ; always without sclerotic induration of the 
base, and, however long its duration, never followed by 
the signs of systemic syphilis. 

One well-marked and fortunately rare type of serpigi- 
nous or chronic chancroid has been found so rebellious 
to treatment and so persistent in its course that it has 
been regarded by some writers as a modification of true 
chancroid in the direction of lupus. Some of the forms 
of so-called esthiomhie unquestionably belong to this 
category. In obstinate cases the chancroid persists for 
a year or more, very slowly spreading over the abdom- 
inal surface upward, or downward over the inner or 
outer face of the thigh. The ulceration may spread 
superficially or deeply, and in the latter case may even 
be subcutaneous, burrowing immediately beneath the 
skin or the fascia, undermining the tissues in areas of 
the size of a large platter, with fistulous tracts uniting 
its lines of subcutaneous excavation, the latter here and 
there communicating with the surface by irregularly set 
ulcerating openings, suggesting the '* man-holes " of a 
system of sewerage. Here an empurpled integument 
covers the ramifications of the burrows, ridges, and open 
ulcers, a thin, virulent secretion destroying slowly what 
it touches. These features together furnish a charac- 
teristic picture. This severe complication of chancroid 
occurs chiefly in women, particularly among filthy pros- 
titutes, but it is also seen in men and among those 
debilitated by alcoholism, venery, poverty, hospitalism, 
and cachexia. 



CHANCROID. 309 

Gangrene, when it complicates chancroid, is usually 
so promptly destructive of all parts affected that it often 
serves at once to end the specifically morbid process. 
Here the accident may be rapid or slow of occurrence, 
and the gangrene may be superficial, removing merely 
the sore itself and the tissue on which it rests ; or the 
process may be deep, the slough embracing the glans 
or the entire body of the male organ, even the testicles 
being laid bare in the scrotum. Here a blackish or 
greenish-black slough is seen, involving the whole or a 
large part of the sore and the tissue upon which it rests. 
This complication of chancroid is distinguished from 
phagedena in that it more often attacks filthy men than 
women. At the outset there is usually a coincident in- 
flammation of the surrounding parts, which often assume 
an erysipelatous appearance. These severe accidents 
of chancroid are very much rarer in modern practice 
than in the days preceding the modern methods of 
asepsis. 

Lymphangitis and Lymphadenitis (Bubo ; Chan- 
croidal bubo ; Chancroid adenopathy ; vernacular, 
'' Blue-ball ;" Ger. Virulenter Bubo ; Fr. Boubon). — In- 
flammation of the lymphatic vessels and the perivascular 
tissue is a complication of chancroid, as also of the 
other venereal diseases. It is rather rare as compared 
with other accidents of the disease. When the inflam- 
mation is well marked the lymphatic trunks may be 
recognized as tender, indurated, and painful cords, of the 
thickness of a wheat-stalk or of the little finger, stretch- 
ing away from the site of the lesion toward the inguinal, 
pubic, or crural regions. At times the overlying integu- 
ment is unchanged in color, at others it is of an erythem- 
atous hue, and in extreme cases it may even threaten 



310 SYPHILIS AND THE VENEREAL DISEASES. 

to burst, as in the case of the glandular disease accom- 
panying the same process. 

The lymphadenitis, or bubo, of chancroid differs from 
that of syphilis chiefly in its inflammatory character and 
its marked tendency to the production of an abscess ter- 
minating by bursting. Primary syphilitic adenopathy, 
it will be remembered, is characterized by the involve- 
ment of several glands, occasionally of but one, in 
anatomical connection with the region of infection. 
When the chancre has a genital site, a chain ("pleiad ") 
of densely indurated glands, each of nearly the size and 
firmness of a marble, neither painful nor tender, can be 
recognized in one or both groins. Save in the case of 
" mixed " infection none of these glands exhibits a tend- 
ency to inflammatory softening or degeneration, as in 
the case of the lymphadenitis of chancroid. 

When the bubo accompanying chancroid threatens 
to burst, one or more tender and painful points can be 
discovered, usually in the inguinal region, representing 
the sites of as many glands. With greater or lesser rapid- 
ity, often in the course of but a few days, all these points, 
but more often one predominantly, enlarge until the 
glandular character of the tumor becomes evident, with 
aggravation of the pain and tenderness, both with and 
without motion of the muscles in the vicinity. In typical 
cases the gland, at first merely voluminous and movable, 
becomes fixed, and the overlying skin is involved in the 
periglandular inflammation, being then dusky, empur- 
pled, and gradually thinned, precisely as in the case of 
the integument covering a syphilitic gumma about to 
burst. Then follow, in course, fluctuation, softening, 
rupture of the capsule of the gland, which becomes con- 
verted into an abscess, and escape of the contents either 



CHANCROID. 311 

into the neighboring subcutaneous tissue or externally 
through a rent in the skin. When several glands coin- 
cidently suppurate a single enormous abscess may result 
from their fusion. The pus evacuated spontaneously or 
by surgical procedures is- foul, thick, hemorrhagic, and 
at times auto-inoculable, as in the case of the pus fur- 
nished by the original chancroid. The abscess-cavity, 
when examined after spontaneous rupture, exhibits 
undermining pockets, grayish, pus-soaked walls, detritus 
of tissue, and encroachment on the cavity by other 
glands in the vicinity, either threatening suppuration or 
only incidentally and less seriously involved. 

In some cases of spontaneous rupture of the abscess 
the lips of the rent speedily become inoculated, and the 
resulting sore exhibits all the evidences of an enormous 
inguinal chancroid, its long axis lying irregularly paral- 
lel with the line of Poupart's ligament, its edges steep or 
undermined, its floor pus- and slough-covered, its secre- 
tion foul, its ragged lips teased with every motion of 
the thigh. Many of the enormous chronic chancroids 
already described as supposed varieties of lupus origi- 
nate in gigantic ulcerations of this character. Under 
favorable circumstances, however, with patients of a 
sound constitution and properly treated, the phases of 
repair ensue even after exhibition of serious symptoms, 
and the result is eventual cicatrization with the produc- 
tion of an indelible scar, whether surgical interference 
be or be not employed. 

It is probable, though not wholly demonstrable, that 
in some cases threatening buboes accompanying chan- 
croids undergo a species of abortion by resorption. 
Certain it is that the glands in these instances may en- 
large and become both painful and tender, with the 



result of an eventual resolution short of pursuing the 
career just sketched. Whether in all these cases the 
buboes were of the type commonly denominated " vir- 
ulent," or were merely inflammatory and sympathetic 
phenomena accompanying the original venereal lesion, 
cannot be determined. 

The symptoms of bubo and of lymphangitis are as 
distinctly marked in women as in men, but the rarity 
of these complications among women is remarked by 
all observers. 

In men buboes occur in from lo to 30 per cent, of 
cases of chancroid, the figures changing according to 
the class from which the author collects his statistics. 
Hospital patients are much less liable to exhibit these 
complications than the filthy class of dispensary out- 
patients in large cities. In private practice typical bubo 
in the more cleanly classes is decidedly rare, and may 
occur soon after the first appearance of the chancroid, or 
may succeed complete cicatrization of the inguinal sore. 
Occasionally the bubo develops with typical features 
when there has been no suspicion of chancroid, this 
lesion being discovered later lying behind or near the 
fraenum. At times the bubo, in consequence of decus- 
sation of the lymphatics, forms on the side opposite that 
on which the sore originally appeared. 

The etiology of bubo is in part obscure. Exciting 
causes are, assuredly, weakness of the constitution, filth, 
over-exertion, improper treatment of the original sore, 
neglect of the implicated region aside from lack of clean- 
liness, and enormous multiplicity of lesions. " Virulent " 
bubo may, however, occur when none of these supposed 
causes has been in operation, though, fortunately, this 
event is rare. 



\ 



CHANCROID. 313 

With respect to the presence of micro-organisms of an 
etiological significance in the pus of a chancroid bubo, 
and the possibihty of reproduction by auto-inoculation, 
opinions differ. By some writers it is held that typical 
chancroid of the groin caused by the bursting of a bubo 
in that region results from inoculation of the lips of 
the' wound, not with the pus originally contained in 
the abscess-cavity, but with that furnished by the yet 
unhealed chancroid. The results of experimentation 
are not conclusive. At times the bubo, however, as 
already seen, develops only after the sore has healed ; 
in such cases, of course, the possibility of infection of the 
bubo from the chancroid is set aside. In these cases, as 
also in those where total excision of the chancroid has 
been practised before inoculation-experiments, and where 
the pus employed in such experiments has been with- 
drawn by aspiration from an unopened inguinal abscess, 
the results are not satisfactory. It has already been 
shown that the micro-organism of chancroid has not yet 
been so definitely demonstrated that its presence or 
absence can be trusted in the determination of the char- 
acter of any lesion. Of the micro-organisms of Ducrey 
and Unna, which are unquestionably identical, it may be 
said that they are most often not demonstrable in the pus 
furnished by a chancroidal bubo. It has hence been in- 
ferred that bubo was caused by some ptomaine resulting 
from the invasion of a strepto-bacillus, but all this as yet 
lacks proof Whether, then, the micro-organisms them- 
selves or their toxines are conveyed from the site of 
infection to the gland or glands which suffer as a conse- 
quence, it is merely certain that the germs and their 
products are originally related to the infective process, 
and that in no other disease do inflammation and sup- 



314 SYPHILIS AND THE VENEREAL DISEASES. 

puration of the lymphatic glands present precisely the 
same picture as in the bubo accompanying chancroid. 

Diagnosis. — The indications of importance in the diag- 
nosis of chancroid are, first, when practicable, to exclude 
positively the presence of syphilis, either in initial sclero- 
sis or in later manifestations of sj^stemic disease ; second, 
to remember that the possibility of mixed chancre clouds 
every case until the longest period of incubation of 
syphilitic chancre has elapsed without symptoms of the 
disease ; third, to recall the most significant character- 
istics of the chancroid, which are its occurrence without 
an incubative interval, its lack of induration, its con- 
tinuously purulent character, its multiplicity, its auto- 
inoculability, its inflammatory symptoms, and its bubo. 
In all doubtful cases the decision should be reserved 
until a definite period has elapsed. Periurethral phleg- 
mon is distinguishable by its defined outline and inflam- 
matory character, its frequent complication of a pre- 
viously existing urethritis, and its situation, which is 
usually near the distal extremity of the male organ and 
in the body of the corpus spongiosum. 

In distinguishing between venereal lesions (including 
chancroid) and non-venereal disorders of the genital 
region, the age, occupation, character, habits, and ante- 
cedents of the patient should be considered. An epi- 
thelioma of the penis or of the clitoris is rare in youth, 
while a majority of all the affections acquired in the 
sexual act originate in the second, third, and fourth 
decades. Patients in middle life with no venereal ante- 
cedents are in a different category from those who have 
suffered from repeated attacks of urethritis or " chancre." 
Commercial travellers, women having public occupations, 
and residents of large cities are more exposed to the 



CHANCROID. 315 

accidents of genital infection than are those who Hve in 
the country and those who are surrounded by the safe- 
guards of a home. 

The most striking differences between chancroid, 
syphiHtic chancre, herpes progenitaHs, and a few of the 
more common affections of the muco-cutaneous surfaces 
of the genital region are exhibited in the appended 
table. 



3l6 SYPHILIS AND THE VENEREAL DISEASES. 



History 
Etiology 

Incubative stage 

Lesion : 
site 
character 



Chancroid. 
Occurs in subjects of syphilis and others; prior sexual 

exposure. 
Infection, accidental or intentional, by medium of pus 

from chancroid or chancroidal bubo ; usually in or 

near the ano-genital region. 
None after actual access of virus to lymphatic channels. 

Lesion rarely later than one v^^eek after infection. 

Most commonly genital ; rarely extra-genital. 
Pustulo-ulcerative lesion throughout ; few exceptions. 



number 



color 



contour 



Multiple, as a rule, both at the outset and by subse- 
quent auto -infection. Rarely, though at times, 
unique ; occasionally very numerous. 

Pustule yellowish ; ulcer, when wiped clean, florid ; 
crusts greenish and blackish. 

Round, oval, and, when fused, circular. 



Subjective sen- Pain, tenderness, soreness, occasionally great pain. 

sations 
If ulcerating, base Engorged, soft, supple when not cauterized, rarely 
indurated, 
floor Pus-soaked, slough-covered ; showing ragged tags, 

edges Abrupt, steep, punched-out ; at times undermined. 



secretion 



Foul, purulent, hemorrhagic, often offensive in odor. 



crust 

Inoculabilityand 
auto-inocula- 
bility 

Induration 



Career 



Bulky, blackish-greenish ; often concavo-convex, form- 
ing roof of a pus-chamber. 

Auto-inoculable indefinitely ; with difficulty transmitted 
to animals. Infection of genital region commonest. 

Base, as a rule, non-indurated; supple; if inflamed, 
boggy, indeterminate in outline, non-elastic, attached 
to adjacent tissue; if deeply cauterized or irritated, 
at times indurated, simulating sclerosis of syphilis. 

Usually in uncomplicated cases a cycle, from initial 
pustule to cicatrization, of from six to eight weeks. 
Resulting indelible scar. 



CHANCROID. 



317 



Chancre. 
History Follows infection at any point of the body, usually in 

non-syphilitic subjects. 
Etiology Infection with syphilitic virus (sexually or by accidental 

or intentional inoculation, as in tattooing, vaccina- 
tion, nursing upon the nipple, etc.). 
Incubative stage Usually between ten and thirty days; average, twenty- 
one days. 
Lesion : 

site Any infected region of the body. 

character Minute plane lesion with erosive surface, dry or moist 

papule, or large tubercle, 
number Usually single, rarely multiple ; if the latter, multiple 

at the outset, and not by later auto-inoculation. 



color 



contour 



Subjective sen- 
sations 
If ulcerating, base 



Raw-ham; dull-reddish; scales at times changing the 

hue. 
Highly irregular, observing chiefly the peculiarities of 

anatomical site ; when on a free plane surface, 

usually rounded or oval. 
Often entirely wanting; at times somewhat painful. 

Thin, circumscribed, or enormous and well-defined. 



floor Shallow, erosive, smooth. 

edges Scarcely apparent ; often ill-defined ; at times elevated 

like the lips of a small crater (Hunterian type), 
secretion Scanty and thin, unless accidentally or intentionally 

irritated, 
crust Scarcely ever formed. 



Inoculability and 
auto - inocula- 
bility 

Induration 



Non-auto-inoculable save in ** mixed" infection. 



Characteristic; marked; thin and papery; or dense, 
ivory-like, non-adherent, movable, insensitive to 
pressure, defined. 



Career 



May persist for months after general symptoms appear, 
or may practically disappear within six weeks; 
usually, in uncomplicated cases, no scar resulting. 



3l8 SYPHILIS AND THE VENEREAL DISEASES. 

Chancroid. 
Accidents : 

lymphangitis May occur, but rare, 

bubo In one-tenth to one-third of male cases, 

phagedena In neglected and ill-treated cases not rare, 

gangrene In exceptional cases sevex-e and even grave. 

Systemic results In protracted cases deterioration of general health. 

Influence of Systemic treatment worthless; local treatment of high- 
treatment est value. 



Date of appear- 
ance 
Symmetry 

Frequency 
Number of in- 
volved glands 
Size 

Inflammation, 
glandular and 
periglandular 

Induration 

Career 

Infectiveness of 

pus 
Diagnostic value 

of treatment 
Lymphangitis 
Situation 

Color of overly- 
ing integument 

Pain and tender- 
ness 

Career 



Bubo. 
At any time, even soon after healing of lesion. 

Usually monolateral, with involvement of several glands, 

one predominantly; occasionally bilateral. 
One-tenth to one-third of all cases in men. 
Often one gland only, rarely more than two, typically 

involved. 
From large nut to goose's &gg; at times as large as 

small cocoanut. 
Classically developed, with involvement of overlying 

integument, heat, pain, redness, and swelling. 

Non- indurated. 

Resolution; or, moie commonly, suppuration, with 
indelible scar resulting. 

In cases auto-infection from pus; in others non-auto- 
inoculabilit>'. 

General treatment unavailing ; local treatment impera- 
tive. 

Rare, but of occurrence. 

Usually in males, along dorsum and toward root of 
penis. 

Inflammatory hue. 

Often well marked. 

Proceeds to resolution, more rarely to suppuration. 



CHANCROID. 319 

Chancre. 
Accidents : 

lymphangitis Occasionally noticed ; then painful, 

bubo Characteristic and constant, 

phagedena Almost never occurs. 

gangrene Very rare ; occurs only in cachectic patients. 

Systemic results Occur in various grades of severity in all cases. 

Influence of Effective at an early stage, 
treatment 



Bubo. 

Date of appear- Within a fortnight after development of initial sclerosis. 

ance 

Symmetry Bilateral as a rule ; at times symmetrical. 

Frequency Constant. At least one gland is affected in every case. 

Number of in- Usually several glands, one or both sides of the body. 

volved glands 

Size Uniformly moderate, cherry- to large-marble-sized. 

Inflammation, None in uncomplicated cases. 

glandular and 

periglandular 

Induration Firmly and densely indurated. 

Career Termination by resolution ; scars rarely result. 

Infectiveness of No pus, save in mixed cases. 

pus 

Diagnostic value General treatment effective. 

of treatment 

Lymphangitis Rare. 

Situation Usually in Hnes proceeding from site of sclerosis. 

Color of overly- Rarely, though occasionally, congested, 

ing integument 

Pain and tender- May be absent or as severe as in chancroid. 

ness 

Career Rarely suppuration ; usually resolution. 



320 SYPHILIS AND THE VENEREAL DISEASES. 



Herpes Progenitalis. 

History Previous recurrence at irregular intervals after digestive 

disturbances, venery, unci eanliness, and other sources 
of general or local irritation. 



Etiology 



Incubation 
Lesion : 



All local irritations, chemical, mechanical, and physio- 
logical, and the general factors producing the neur- 
oses. 

None. 



character Vesicles and sequels of vesicles. 



number Multiple, as a rule; rarely very 

grouped, occasionally confluent. 



numerous, often 



color 



Floors of broken lesions slightly florid. 



contour 



Separate lesions rounded. 



subjective 
sensations 
If ulcerating 



base 
floor 
edges 
secretion 
crust 
Inoculability and 
auto-inocula- 
bility 
Induration 



Tingling, pricking, itching. 

No true ulcer forms. When ulceration occurs, there is 
invariably mixed infection ; at times exceedingly 
superficial erosions occur. 

Imperceptible. 

Smooth, at times florid. 

Scarcely appreciable. 

A thin, colorless serum. 

Very superficial and thin, like a deUcate scale. 

Only in cases of mixed infection. 



Absolutely none ; pseudo-induration produced by caus- 
tics, etc. injudiciously or improperly applied. 



CHANCROID. 



321 



Other Local Disorders of the Skin and Mucous MeiMbrane. 



History 



Etiology 



Incubation 
Lesion : 

charactei 



number 



color 



contour 



subjective 
sensations 
If ulcerating 



In balanitis, the same local irritations as in herpes; in 
verruca, usually precedent gonorrhoea; in psoriasis 
and eczema, lesions of other regions ; in epithelioma, 
persistence for long period before examination. 

Local irritations in eczema and balanitis; infection in 
scabies; irritating secretions (gonorrhoeal, etc.) in 
verruca. 

None. 

Superficial multiple and confluent excoriations in balan- 
itis; pustules in eczema and scabies; scales in 
eczema and psoriasis ; warty papules or plaques in 
epithelioma ; warty growths in verruca. 

Usually multiple in all ; occasionally but one pustule in 
scabies, and a single verruca; often patches in 
eczema and psoriasis. 

Whitish in psoriasis ; yellowish in scabies, with black- 
ish cuniculus; reddish, crimson, and purplish in 
balanitis ; florid or smeared with whitish mucus in 
verruca; dull-reddish in epithelioma. 

Irregularly rounded excoriations in balanitis ; defined 
patches in psoriasis and some of the eczemas ; usually 
pedunculated warts ; poor definition in epithelioma. 

Itching in scabies and eczema ; occasionally burning 
in epithelioma. 

Ulcer only in late stages of epithelioma and in mixed 
infection of balanitis. 



base 

floor 

edges 

secretion 

crust 



Insignificant. 
Insignificant. 
Insignificant. 
Insignificant. 
Insignificant. 



Inoculability and Only in cases of mixed infection. Scabies transmitted 

auto-inocula- by acari; a few of the eczema forms are infective 

bility from the presence of trichophyton, mucors, etc. 

Induration None save in well-developed epitheliomatous wart. 



21 



322 SYPHILIS AND THE VENEREAL DISEASES. 

Herpes Progenitalis. 
Accidents : 

lymphangitis None save in mixed cases, 
bubo None save in mixed cases. 

phagedena None save in mixed cases, 
gangrene None. 

Systemic results None. 

Influence of Local treatment effective in two or three days; general 

treatment treatment required only for neurotic and gouty states 

in recurrent cases. 



Treatment. — The management of the general con- 
dition of the subject of chancroid is usually simple. 
The recumbent position is required in all severe or 
threatening cases, especially when complications exist. 
In the simpler cases no internal remedies are indicated ; 
in others a tonic regimen is urgently required, including 
a generous diet and the use of the ferruginous tonics, 
among which, in this connection, the potassio-tartrate 
of iron has long been especially esteemed. Mercury 
and the compounds of iodine are in unmixed cases 
actually harmful, and should not be employed. 

The local treatment of chancroid is usually pursued 
on one of two lines, the one occasionally supplementing 
the other : The first is by antiseptic dressings ; the 
second aims at obliteration of the lesion by surgical or 
chemical measures. 

Antiseptic treatment is always indicated, and in the 
end is probably the most satisfactory for the majority 
of all cases. By this method the sore, as soon as its 
character is fully determined, is washed frequently with 
lotions containing either boric acid, carbolic acid, or 
corrosive sublimate — the first in saturated solution, the 
second in the strength of i part to 50, the third in the 



I 



CHANCROID. 323 

Other Local Disorders of the Skin and Mucous Membrane. 
Accidents : 

lymphangitis None save in epithelioma of advanced grade. 

bubo Occurs in severe scabies and eczema (adenopathy of 

sympathy), 
phagedena Only in grave epithelioma, 
gangrene Only in complicated and grave epithelioma. 

Systemic results None save cachexia in grave epithelioma. 
Influence of Local treatment usually effective promptly in balanitis, 

treatment verruca, some of the eczemas, and some of the epi- 

theliomata ; psoriasis often obstinate. 

strength of i part to lOOO or 2000. The first named is 
preferred, and, when it is possible to immerse the entire 
organ, should be employed as a continuous local hot bath 
of the temperature most grateful to the patient. When 
employed intermittently, the immersions or washings 
should be made as often and for a space of time as long 
as practicable. Mercurial and carbolized fluids are better 
employed as lotions. 

At the outset all crusts should be removed and the 
pus washed away in warm water with the aid of soap, 
after which, so far as possible, the pultaceous floor of 
the ulcer should be cleansed. The surface may then be 
sprayed with peroxide of hydrogen, or with water to 
which has been added, in the cup of the atomizer, from 
10 to 15 drops of iodized phenol : 

^. Acid, carbolic, 3j ; 

lodin. tinct., f 3ss ; 

Glycerin., 

Spts. vin. rect., aa. f 3ij ; 

Aq. dest, ad ij.— M. 

Sig. For external use only, diluted. 

After the washing either a dry or a wet dressing may 



324 SYPHILIS AND THE VENEREAL DISEASES. 

be employed. The former answers well for most cases, 
the ulcer, when dried, being well dusted with either 
europhen, iodol, aristol, boric or salicylic acid, or 
hydronaphthol. The three first usually answer well ; 
the fourth and fifth named are sometimes productive 
of pain when applied over a very sensitive sore, and 
hence should often be reduced with starch, talc, or bis- 
muth. Hydronaphthol is usually mixed with fuller's 
earth i part of the former to 50 or lOO parts of the lat- 
ter. Iodoform is chiefly valuable as a local narcotic, but 
it is highly objectionable on account of its odor. It may 
be ordered for patients confined to the room for a brief 
time, when it is not necessary to conceal the character 
of the disorder from others visiting the apartment. The 
deodorized preparations of iodoform are not preferable 
to the other powders named above, which have no 
specially disagreeable odor. Calomel, pure or mixed 
with equal parts of the subnitrate of bismuth, is useful 
as a resort where other preparations do not answer well. 
In fact, many patients exhibit an idiosyncrasy with 
respect to these local applications. After the antiseptic 
treatment of the sore wet dressings are employed by 
laying a pledget of lint moistened with antiseptic astrin- 
gent, sedative, or even stimulating solutions. To the class 
of preparations first named belong those employed in the 
lotions already described ; to the second class belong 
solutions of sulphate of copper and sulphate of zinc, 
10 to 20 per cent, strength; to the third class, solutions 
of cocaine, morphia, and lead (often added to ingredients 
suggested for other lotions), as well as the black and 
yellow washes ; in the class last named are included 
alcoholic lotions, embracing the aromatic wine, popular 
with the French. 



CHANCROID. 325 

The destruction of the chancroid is wrought by the 
aid of the actual cautery (Pacquehn knife, galvano- 
cauterization apparatus, hot iron), and by chemical 
agents, including nitric and pure carbolic acid, zinc 
chloride, caustic potash, cupric sulphate, and the nitrate 
of silver. The last is, however, ineffective for complete 
destructive action, and is chiefly useful as a stimulating 
application to sluggish lesions, for which purpose it is 
admirably adapted. Gaylord recently advised a 40 per 
cent, formaline solution. All destruction of chancroids 
by these methods should be accomplished with strict 
antiseptic precautions. 

The operative procedures by the instruments of the 
surgeon are curetting the sore itself and the neighbor- 
ing tissue, and excision of the part, with attempts at 
securing union — such immediate union as is possible 
after the surgical excision of simple lesions of moderate 
size. Both methods require the strictest observance of 
antiseptic precautions, and both, in the best of hands, 
have been followed by infection of the resulting wound, 
as also by the development of syphilis in cases where 
the diagnosis was not well established. 

The objections to the destruction of chancroids by 
each and all of these severe measures are not to be 
lightly set aside. They may briefly be summarized as 
follows: (i) These destructive procedures obscure and 
aggravate the existing local disorder. It is in many 
cases difficult, if not impossible, at the date when destruc- 
tion is practised, to make certain that the case is not one 
of mixed infection ; and, without question, initial scle- 
roses thus treated are apt to exhibit excessive induration 
at the base of the sore. No practitioner can be assured 
that a chancroid will not be complicated with syphilis 



326 SYPHILIS AND THE VENEREAL DISEASES. 

until about one month has elapsed after the first appear- 
ance of the lesion ; hence all destructive procedures 
undertaken during the first month of the existence of 
a chancroid may be disastrous to an on-coming syphilis. 
(2) Many of these operations, even when performed 
with the utmost care and repeated, utterly fail of accom- 
plishing the end in view. The sore, instead of becoming 
converted into a simple ulcer, the desired issue in all 
attempts of this class, becomes an ugly and intractable 
lesion, persisting unaccountably, often without exhibition 
of classical symxptoms of chancroid, the despair of the 
inexperienced and the horror of the patient after the 
suffering undergone in the heroic and ineffectual treat- 
ment to which he has been subjected. 

On a careful survey of the field, it seems probable that 
destructive treatment of chancroids will before long 
follow in the wake of the now practically abandoned 
attempts to annihilate the syphilitic chancre. 

Continuous Inuncrsion. — There is no treatment of the 
threatening or actually destructive chancroid comparable 
in value with the local or general continuous water-bath. 
Its value depends upon the fact that the pathogenic 
microbes of the disease lose their vitality at a high tem- 
perature which is tolerable by the body. The patient, 
when the part upon which the sore is seated can be 
immersed, spends the greater part of the wakeful hours 
of the day with his ulcer wholly submerged in water as 
hot as can be tolerated ; at times boric acid may with 
advantage be added to the bath. In other cases it is 
much easier to employ the sitz-bath, in which the 
patient partially reclines with the entire ano-genital 
region immersed, the water of all such baths being 
maintained at a high temperature by the aid of supplies 



CHANCROID. 327 

from a source of heat. The patient leaves the bath 
only for the purpose of evacuating the bladder and 
bowel. In all grave cases both the night and the day 
are spent in the water, the patient being, of course, 
under the constant supervision of a trained nurse. The 
most formidable of the phagedenic, sloughing, and gan- 
grenous lesions with destruction of tissue are thus 
readily and even brilliantly converted into healthy 
ulcers which speedily assume the phases of repair, if 
effective constitutional treatment of the patient, with 
proper food and tonics, be at the same time secured. 

All ointments are contraindicated in chancroids in a 
toxic condition, seeing that the germ of the disease finds 
a suitable culture-field in these greasy applications even 
when they are medicated. There are but a few indica- 
tions for their employment ; one is when the lint over- 
lying the dry or wet dressing adheres so firmly to the 
part, in consequence of the discharges which leak through, 
that when the dressing is removed there is bleeding from 
the edge or floor of the ulcer. Another exception relates 
to chancroids of the urethra: in these cases the lint may 
be spread with carbolated vaseline — not in contact with 
the sore itself, but merely to facilitate removal of the 
dressings. 

Treatment of Complications. — Urethral chancroids may 
generally be exposed by the aid of an ear-speculum or a 
pair of urethral forceps, after which the treatment of the 
sores may be practised as in the case of those existing 
in other regions. Pledgets of lint smeared with petro- 
leum jelly and medicated with one of the powders 
already named may be inserted in the urethra. Urinat- 
ing with the penis immersed in hot water is of great 
service in relieving the pain of micturition, and aids in 



328 SYPHILIS AND THE VENEREAL DISEASES. 

securing repair of the ulcer. The black and yellow 
washes, pure or dilute, may subsequently be applied. 

Chancroids complicated with phimosis, the sore being 
so imprisoned that it cannot be exposed within the sac 
of the prepuce, are usually the source of alarm to the 
patient and anxiety to the physician, but the real danger 
in any case is much less than is generally believed. 
With the aid of careful syringing of the sac through 
the preputial orifice, sufficient cleanliness of the surface 
of the sore may usually be secured to ensure repair 
for most cases, especially as lotions may be employed 
about the integument of the tumid and often reddened 
and empurpled prepuce, serving to still further reduce 
the inflammatory symptoms. In other cases, however, 
the chancroid becomes threatening, and exposes the 
patient to the danger of a slough forming, after the fall 
of which the glans escapes through a species of button- 
hole through the swollen and distorted prepuce — a rare 
accident. In these and other severe cases resort must 
be had to operative procedures. A serious objection, 
however, is the danger of auto-infection of the wound 
inflicted by the surgeon. As a rule, therefore, it is wise 
to reserve operative interference for cases of emergency. 

Circumcision of the prepuce, or incision either over 
the dorsum or on one side or another of the prepuce (as 
advocated by Taylor), may be practised in these emer- 
gency cases ; but the surgeon will always do well to 
remember that in the best of hands and with every pre- 
caution infection in these cases has occurred repeatedly. 

The operative treatment of the bubo of chancroid is 
gradually receding into the class of reservations advo- 
cated in the management of the sore itself Early sur- 
gical treatment of these complications, once indiscrimi- 



CHANCROID. 329 

nately advocated for all cases, has at last given place to 
a more judicial waiting for the evolution of the malady 
to the point where intervention is inevitable. 

The abortive treatment of the bubo includes rest in 
the recumbent position (which is perhaps the best of all 
measures having this end in view) ; hot fomentations 
with boric acid; cathartics and a restricted diet; the 
local application of leeches ; and applications with a 
view to a resolvent effect, such as the tincture of iodine, 
mercurial ointment (i part to 10 of lanolin), belladonna 
ointment, and salves containing the salts of iodine, as, 
for example, the compound iodine ointment. Pressure 
by a spica bandage and by the application of bags filled 
with hot shot is also of value. The common treatment 
by painting with tincture of iodine is by most experts 
practically abandoned as useless. The internal remedies 
employed, such as sulphide of calcium and mercury, are 
of little, if any, value. 

Injection of chancroidal buboes has been practised 
with hot solutions of boric acid, bichloride and benzoate 
of mercury, and carbolic acid. Dangerous results have 
followed some of these injections, and those containing 
the mercuric benzoate have in cases been found ineffec- 
tive. 

The operative treatment of bubo is by free incision, 
all antiseptic precautions being strictly observed, with 
excision of all glands wholly or partially implicated in 
the morbid process, subsequent curetting of the surface, 
and careful washing with hot borated solutions. The 
subsequent dressings are with iodoform gauze. These 
operations, when carefully practised, are followed by 
exceedingly satisfactory results, the bubo being speed- 
ily converted into a healthy ulcer. 



330 SYPHILIS AND THE VENEREAL DISEASES. 

As the resulting scar is, however, both deep and 
indehble, and ever afterward points unmistakably to the 
nature of the original disorder, efforts are constantly 
being made to rob these procedures of some of their 
surgical severity. With special care many surgeons in 
private practice now succeed in penetrating the abscess- 
cavity of the gland with a fine bistoury or a large 
aspirator needle. The evacuation of the contents by 
squeezing is followed by injection of a hot borated 
solution or, as White suggests, of iodoform ointment. 
Aspiration of the abscess with subsequent injection of 
hot borated water often suffices, without the production 
of a serious scar. 



DISORDERS NOT INVARIABLY 
VENEREAL. 



BALANITIS AND BALANO-POSTHITIS. 

Balanitis is an inflammation of the mucous membrane 
covering the glans penis. It is usually accompanied by 
more or less inflammation of the prepuce (posthitis). 

Etiolog'y. — Balanitis frequently complicates gonor- 
rhoea and chancre, but it may occur independently of 
these affections, and may be non-venereal in origin. It 
is caused by mechanical or chemical irritation of the 
mucous membrane, and it most frequently results from 
retention beneath a long prepuce of gonorrhoeal or other 
pus or of irritating vaginal or other secretions. Neglect 
to cleanse the parts, permitting the normal secretions 
to decompose and become irritating, may be a sufficient 
cause. 

Symptoms. — In the beginning of the inflammation 
the surface of the glans is slightly reddened and is 
covered with a thin, creamy layer of mucus and pus. 
The redness rapidly becomes miore intense, the discharge 
thicker and more profuse. As a result of maceration the 
epithelium is destroyed in patches, leaving irregularly 
outlined excoriations ; these excoriations are usually 
superficial, but they may become quite deep and sim- 
ulate the early stage of chancroid. The inner surface 
of the prepuce usually participates in the process, thus 

331 



332 SYPHILIS AND THE VENEREAL DISEASES. 

producing a balano-posthitis. The entire body of the 
prepuce may be inflamed, with sHght or extensive 
oedema and tumefaction. Inflammatory phimosis — or, 
more rarely, paraphimosis — may result. The inguinal 
glands may become somewhat enlarged and tender, but 
they rarely suppurate. The subjective sensations are 
usually those of slight itching and pricking, most 
marked in the sulcus back of the corona ; but in severe 
cases the glans becomes very sensitive, so that walking 
and other movements of the body are painful unless the 
penis be carefully supported and protected. Scalding 
on urination is usual, especially if phimosis be present. 

With a long,- tight prepuce balanitis may become 
chronic; the surface is then red and velvety, showing 
granular or even warty elevations. 

Diag-nosis. — If the prepuce can be retracted, the 
diagnosis can usually be made without difficulty. The 
excoriations of herpes are preceded by distinct vesicles, 
and other portions of the glans are not inflamed. When 
balanitis follows herpes, the history of the disease fur- 
nishes the only means of determining its origin. Syph- 
ilitic chancre and chancroid are too distinct in their 
characteristics to be confounded unless they are com- 
plicated with balanitis. Careful examination will detect 
the induration of an initial sclerosis, even in the rare 
diffuse forms. The ulcers of chancroid are much deeper 
than the excoriations of balanitis, and the pus is auto- 
inoculable. In severe cases of balanitis it is not wise 
to exclude the possibility of an underlying chancre or 
chancroid until a i^^ days' treatment has reduced the 
redness, swelling, and infiltration of the parts. In gonor- 
rhoea, when the prepuce is long, and especially if the 
preputial orifice be filled with cotton to catch the dis- 



BALANITIS AND BALANO-POSTHITIS. 333 

charge, the pus works backward and covers the glans, 
producing an appearance that may be mistaken for balan- 
itis. Cleansing and inspection of the parts will readily 
reveal the source of the discharge. 

When balanitis is complicated by phimosis, an accu- 
rate diagnosis of the underlying conditions is more dif- 
ficult (see Phimosis). 

Treatment. — The treatment of balanitis without phi- 
mosis is simple. The indications are to keep the parts 
clean and free from pus, and the inflamed surfaces dry 
and separated from each other. The prepuce should be 
retracted and the parts be cleansed in simple warm 
water from two to four times a day. From 3 to 4 per 
cent, of boric acid or i per cent, of carbolic acid may 
be added to the water, but soap or other irritating sub- 
stances should not be used. After washing, the parts 
should be dried gently by patting with antiseptic cotton or 
with a soft cloth, and covered with a fine dusting-powder. 
Over the powder is laid a thin film of the cotton or a piece 
of lint cut to a shape and size that will just cover the 
glans and leave the meatus free. The prepuce is now 
pulled forward to cover all, and the dressing is complete. 
For mild cases a powder containing i part of boric acid 
and from 2 to 4 parts of refined talc is sufficient. Of 
equal service are calomel, bismuth, or zinc oxide, each 
alone, or in combination with one of the others, or re- 
duced with talc. In severe cases, when the surfaces are 
very sensitive, iodoform is excellent and giv^es relief 
Before applying the powder the surface may be wiped 
gently with a solution of nitrate of silver (gr. xx to 3) 
in ^j), and deep excoriations may be touched lightly with 
the solid stick. 

If the powders are not productive of comfort, the 



334 SYPHILIS AND THE VENEREAL DISEASES. 

cotton or lint may be moistened with a mildly astringent 
and soothing solution before it is applied over the 
powder, or the latter may be omitted altogether. Solu- 
tions of carbolic acid (i per cent.), boric acid (2 to 5 
per cent.), dilute lead-water, red wine (.5j to ^ss in Jj), 
or the following may be used : 

^. Zinci sulphat., gr. j-ij ; 

Morph. sulphat, gr. ss. ; 

Atropin. sulphat., gr. \ ; 

Aquae, ^j. — M. 
Sig. For external use. 

As the condition improves, powders will be more ser- 
viceable. For some time after recovery the parts must 
be cleansed daily and the surface of the glans and the 
prepuce be separated by a film of cotton. 

In men who are subject to frequent recurrences of 
balanitis, the mucous membrane may be rendered less 
sensitive and less liable to inflammation by the long- 
continued use of a powder containing from lO grains to 
\ ounce of tannic acid to the ounce of talc, starch, 
or lycopodium. 

PHIMOSIS. 

In severe forms of balano-posthitis — usually when 
secondary to chancre, chancroid, or gonorrhoea — the 
swelling and infiltration of the parts may be sufficient 
to prevent retraction of the prepuce back of the glans, 
thus producing an inflammatory phimosis. If a man 
with congenital phimosis more or less complete acquire 
a venereal disease, inflammation of the tissues is almost 
sure to follow, since cleansing of the parts is very dif- 



PHIMOSIS. 335 

ficult, and irritating discharges are retained in contact 
with the membrane. 

Symptoms. — The swelHng, oedema, and inflammatory 
symptoms may be shght, giving the patient httle incon- 
venience, or they may be severe and very painful. The 
distended glans is then covered by a reddened, sensitive, 
and greatly swollen prepuce, increasing the distal ex- 
tremity of the penis to several times its normal size and 
giving the organ a distorted or club shape (Fig. 12). 




Fig. 12. — Phimosis from gonorrhcea (CuUener). 

The discharge escapes from the narrow opening of the 
prepuce, and may dry in bulky crusts around the thick- 
ened edges. Sometimes there is excessive oedema and 
swelling, with but slight inflammation and discharge. 
Pressure may interfere with circulation and result in 
gangrene of portions of the prepuce or rarely of the 
glans. Gangrene first appears upon the inner surface of 
the prepuce, and is preceded on the outer surface by 
evidences of interrupted circulation — namely, a dark-red, 
livid, or bluish color of the skin. If left to itself, the 
gangrene usually destroys enough of the prepuce to 
release the glans and relieve the pressure ; the circula- 
tion being thus restored, the slough is thrown off and the 
surfaces cicatrize, leaving an irregular, ragged prepuce. 
As a result of repeated inflammations the prepuce 



336 SYPHILIS AND THE VENEREAL DISEASES. 

may become permanently thickened and hardened, so 
that its retraction is impossible. When a series of soft 
chancres have been located at the orifice of the pre- 
puce, the resulting scars may contract and produce 
phimosis. 

Diagnosis. — An accurate diagnosis of the underlying 
conditions in inflammatory phimosis is difficult and 
often impossible. When syphilitic chancre is present 
and sufficiently developed, its induration may be felt 
through the prepuce, and typical enlargement of the 
inguinal glands may be detected. A hidden chancroid 
is frequently followed by one or more chancroids at the 
orifice of the prepuce, the result of auto-inoculation ; 
and, since the retention beneath the prepuce of infectious 
pus favors absorption, such a chancre is apt to be fol- 
lowed by an inflammatory or a virulent bubo. In doubt- 
ful cases the history may be of value ; or a few days of 
treatment may reduce the swelling and inflammation 
and render an accurate diagnosis possible. If gonor- 
rhoea is present, it can be detected even when the meatus 
cannot be exposed. The preputial sac is cleansed by 
inserting between the glans and the prepuce the tip of a 
syringe or an irrigator and injecting an aseptic solution 
until the fluid comes away clear. The patient then uri- 
nates in one or two glasses. The presence of pus in the 
urine indicates gonorrhoea. 

Treatment. — The preputial sac should be irrigated 
three or four times daily with warm water, which may 
contain I per cent, of carbolic acid or 3 per cent, of boric 
acid. The nozzle of the syringe or irrigator, gently 
inserted between the glans and the prepuce, should be 
directed in turn to every part of the sac, and sufficient 
fluid should be used to cleanse the sac thoroughly of all 



PHIMOSIS. 337 

pus and other accumulated matter. The flat nozzles 
made for this purpose are excellent, and their use 
excludes the possibility of injecting the urethra — a 
mistake that should carefully be avoided. The cleansing 
of the parts may be accomplished less perfectly by 
wiping out the sac with bits of cotton wrapped on the 
ends of wooden toothpicks. After cleansing the sur- 
faces one of the soothing or astringent lotions recom- 
mended for balanitis may be injected into the sac. In 
the large majority of cases a few days of this treat- 
ment suffice to reduce the inflammation and to render 
retraction of the prepuce possible. If swelling and 
oedema are extensive and inflammatory symptoms are 
severe, the penis should be immersed for twenty minutes 
or more, several times daily, in hot saturated solutions 
of boric acid, and during the rest of the twenty-four 
hours should be supported by dressings that will hold it 
in the groin or over the pubes, in order that position 
may favor return circulation. If gangrene is feared, the 
patient should lie on his back, with the penis supported 
and constantly wrapped in boric-acid fomentations as 
hot as can be tolerated. Tonics should be given when 
indicated by the general condition of the patient. Cir- 
cumcision is rarely necessary, and when performed upon 
an inflamed prepuce the operation gives unsatisfactory 
results. If gangrene is imminent, calling for immediate 
relief of pressure, or if it be necessary to expose a 
phagedenic chancre of the glans, it is well to slit up 
the dorsum of the prepuce. If soft chancre be present, 
any freshly cut surfaces are certain to become infected. 
If gangrene has begun in any part, pressure should be 
relieved by incisions, hot fomentations should be applied, 
and the patient should be kept quiet in bed. Quinine 

22 



33^ SYPHILIS AND THE VENEREAL DISEASES. 

and tonics should be given to meet the indications of 
each case. 

In adults, congenital phimosis and phimosis due to 
thickening of the tissues or to cicatricial contraction 
should be treated by circumcision. 

PARAPHIMOSIS. 
When a short prepuce becomes inflamed and oedema- 
tous, it is apt to roll back of the glans, where it rapidly 
becomes more swollen and infiltrated until it cannot 
be returned to its normal position. This form of para- 
phimosis is usually mild in type. A more serious form 
often occurs where a longer prepuce with a narrow 
opening, especially if rendered yet narrower by inflam- 
mation, is slipped back of the glans. This may occur in 
coitus or in cleansing the glans, but is most frequently 




Fig. 13. — Paraphimosis (Cullerier). 

found complicating hard or soft chancres or other local 
disorder. The retraction may be the result of excessive 
swelling, of accident, or of failure to return the prepuce 
over the glans after local treatment and dressing. 

Symptoms. — In spontaneous paraphimosis due to in- 
flammation of a short prepuce the most prominent 



PARAPHIMOSIS. 339 

symptom is the mass of swollen and oedematous tissue 
back of the glans. The swelling is often irregular in 
form, larger below than above, and is usually soft, puffy, 
or doughy. The glans is but slightly if at all affected, 
and subjective symptoms are wanting. If the condition 
is allowed to persist, the infiltration of the tissues may 
increase until the swelling becomes tense, white, and 
glistening. In such cases the glans becomes more or 
less swollen and darkened in hue, showing an interference 
with circulation. Strangulation rarely follows. 

When a long prepuce with a tight opening is re- 
tracted and allowed to remain, it produces constriction 
of the penis back of the glans, which soon becomes 
turgid and livid. The soft tissues of the prepuce in a 
few hours become greatly inflamed and swollen. Just 
back of the glans is a large roll of tense, glistening 
oedematous tissue, which may be white or of a reddish 
color (Fig. 13). Back of this roll, and often concealed 
by it, is a deep furrow produced by the constricting band 
or ring. Behind this furrow is usually another smaller 
fold of swollen and oedematous tissue. At first these 
swollen, oedematous folds are soft though tense, but after 
a few days plastic infiltration makes them thicker and 
firmer, and may even cause adhesions. 

Strangulation occurs when the constricting band shuts 
off all circulation from the parts in front. The glans is 
then even more swollen, is darker in color, becoming 
purplish or almost black, and is cold and insensitive to 
touch. If this condition be untreated, it is rapidly fol- 
lowed by gangrene of the prepuce or of the glans. 
Fortunately, in the large majority of cases gangrene 
destroys the constricting band in time to save the glans. 

Treatment. — In all recent cases an attempt should be 



340 SYPHILIS AND THE VENEREAL DISEASES. 

made to return the glans back of the constricting ring. 
If reduction is not accomplished, and there is no im- 
mediate danger of strangulation, rest, elevation of the 
penis, and the constant application of boric-acid fomen- 
tations will promote absorption of the infiltration, and 
will in almost all cases render further operation unnec- 
essary. In addition to fomentations, astringent lotions 
may be used. The affected part should be watched 
closely to prevent the possibility of strangulation and 
gangrene. 

If strangulation occur, immediate reduction or opera- 
tion is imperative. If an even pressure be exerted 

with the fingers or with a 
-:i;:i;;!;;;^i; :•::::: P narrow bandage, the glans 

may be reduced sufficiently 
to enable it to pass through 
the constricting ring. In 





Figs. 14, 15. — Reduction of paraphimosis. 



addition to pressure, ice or iced water may be applied, 
and the oedematous fold in front of the ring may be 
scarified in order to allow the serum to escape. If 
these measures fail, the patient should be put under the 
influence of an anaesthetic, when the resulting relaxation 



PARAPHIMOSIS. 341 

of the tissues greatly aids in reducing the paraphimosis. 
The corona and the adjacent portion of the prepuce 
should be oiled, and, when possible, some of the oil 
should be worked under the constricting band. With 
the thumb and the forefinger of the left hand encircling 
the body of the penis just back of the stricture, the glans 
is seized with the thumb, index, and middle fingers of 
the right hand, and by them squeezed into the smallest 
possible compass (Fig. 14). Pressure should be exerted 
laterally, in order so to reduce the diameter of the glans 
that the left thumb and forefinger may fetch over the 
preputial constriction. Sometimes the finger-nails may 
be worked under the constriction, and thus aid in the 
reduction. Keyes recommends seizing the penis behind 
the strictured prepuce in the fork of the index and mid- 
dle fingers of both hands, one placed on each side. This 
method gives more even pressure forward. The glans is 
thus compressed between the two thumbs (Fig. 15). The 
rounded end of a hair-pin or a blunt-pointed director 
may be inserted under the constriction on each side, and 
the glans compressed between the digits while the pre- 
puce is slipping forward. 

With the patient under ether reduction can be accom- 
plished in most cases if sufficient care and patience be 
exercised ; but if all attempts fail, it is necessary to 
divide the constricting band of tissue. A tenotomy-knife 
or a blunt-pointed bistoury with the blade flat is inserted 
under the band. When possible, the blade is brought 
to the median line above before the knife is turned so 
as to bring the edge upward, and the ring is divided 
from within outward. After reduction the case may be 
treated as one of inflammatory phimosis. 

In reducing paraphimosis so much manipulation and 



342 SYPHILIS AND THE VENEREAL DISEASES. 

handling of the parts are necessary that, in case a con- 
tagious ulcer is present, the surgeon is in danger of be- 
coming infected unless the epidermis of his hands is 
sound. 

In the older cases of paraphimosis in which oedema is 
the chief, if not the only, symptom, rest, position, and 
warm dressings may be supplemented by the application 
of pressure and of strong astringent lotions. For such 
cases Keyes recommends the free use of collodion. 

VENEREAL WARTS. 
This title is applied to vegetations appearing upon 
the genitals and the genital region. The term is not 
strictly accurate, for, while these warts are commonly as- 
sociated with venereal diseases, and are almost always 
the result of exposure of a delicate membrane to 
venereal secretions (gonorrhoeal, syphilitic, leucorrhceal, 
etc.), the lesions may spring from other causes (unclean- 
liness, warmth, and moisture). In pregnant women they 
are sometimes found bordering the vulva, where they 
are doubtless produced by irritating discharges. It is 
possible that these vegetations possess a distinct though 
feeble contagious element, but this contagiousness has 
never been demonstrated. In men the favorite location 
of venereal warts is in the sulcus back of the glans penis, 
but they are found over all parts of the glans and the 
prepuce, and occasionally within the urethra. They may 
also appear on any portion of the penis, scrotum, per- 
ineum, and inner surface of the thighs, and about the 
anus. In women they are commonly found over and 
about the vulva, over the perineum and anus, and some- 
times within the vagina. They may be single, but they 
are usually multiple, and they vary in size from a single 



VENEREAL WARTS. 343 

filiform projection to a close aggregation of filiform or 
papillary elevations forming a mass as large as a hen's 
<tg<g or even larger. Individual papillae are usually 
acuminate, but may be rounded, club-shaped, or flattened. 
Instead of becoming aggregated in larger masses, they 
may appear as smaller but more numerous elevations ; 
at times hundreds coexist upon the genitals and the 
neighboring regions. They may so fill the preputial sac 
as to cause phimosis, paraphimosis, or, rarely, gangrene. 
When situated on a free surface, where they are dry, 
they are firmer and have the color of the normal skin, 
but when protected and moistened they are softer, are 
pinkish or bright red in color, and are covered with a 
whitish or yellowish puriform mucus having a very 
offensive odor. The larger masses may be peduncu- 
lated or sessile, and form irregular-shaped vegetations re- 
sembling in appearance cauliflower or the comb of a cock. 
Under the influence of warmth and moisture they grow 
luxuriantly and rapidly by peripheral extension. When 
larger and flattened they may be mistaken for condylo- 
mata. The latter are broader and flatter than venereal 
warts, are not made up of so many small projections, 
and are found in connection with other evidences, or 
with a history, of syphilis. Papillary epithelioma may 
be distinguished from a venereal wart by the indurated 
base and border of the cancerous growth, its slower 
development, its tendency to degenerate and to form 
typical deep ulcers, and the infrequency with which it 
appears before the fortieth year. 

Treatment. — Cleanliness is first in importance. In 
many cases, if the parts be kept clean and covered with 
a simple dusting-powder, the venereal growths gradually 
shrivel and disappear. The treatment recommended for 



344 SYPHILIS AND THE VENEREAL DISEASES. 

balanitis is often efficient ; if necessary, the lotions and 
powders employed in that affection may be increased in 
strength. When persistent, pedunculated masses and 
small vegetations may be removed with the scissors or 
the curette, and the base cauterized with nitric or acetic 
acid, or with nitrate of silver in stick. After such treat- 
ment the surfaces should be kept clean and covered with 
iodoform, aristol, or similar powder. The large growths 
with a broad base will usually shrivel under the applica- 
tion of tannic acid or other astringent powder ; if they 
persist, nitric or acetic acid may be applied once a week 
until the base is destroyed, a powder being used during 
the intervals. If the growth can be kept dry, bichloride 
of mercury in collodion [Z] ' ij) may be applied every 
second or third day. In using this preparation care 
must be taken to prevent its contact with other surfaces 
than those for which it is intended, and the possibility 
of balanitis following its use should always be borne in 
mind. 

HERPES PROGENITALIS. 

This disorder is not always venereal in its origin, but 
in many cases it follows local irritation or inflamma- 
tion caused by venereal diseases, contact with irritating 
secretions, excessive venery, or sexual excitement. A 
long, tight prepuce and a gouty or rheumatic diathesis 
may act as predisposing causes. Neurotic individuals 
seem to be unusually susceptible to the disease. 

Symptoms. — The disorder, which appears in the form 
of one or more groups of minute, pin-head-sized vesicles 
on an inflamed base, may affect any portion of the 
genital organs and the surrounding integument in both 
sexes, though it is much more common in men. In the 



HERPES PROGENITALIS. 345 

male sex it is most frequently found upon the inner sur- 
face of the prepuce, in the sulcus, or on the glans; in 
women, on the hood of the clitoris, on the labia minora, 
and on the inner face of the labia majora. 

The eruption is accompanied, and may be preceded, 
by sensations of burning, pricking, or itching. There is 
usually but one group of vesicles, which contain a clear 
fluid. On the mucous membrane these vesicles rupture 
in a few hours, leaving sharply defined circular excoria- 
tions which, if unirritated, heal in two or three days 
without other treatment than cleanliness. The whole 
process lasts a week or less. When the vesicles 
are situated on the integument, the contents dry and 
form small crusts, which remain for a few days until heal- 
ing is complete. Sometimes the first group of vesicles 
is followed by others, and the disorder is thus continued 
through several weeks. If the lesions be irritated (by 
coitus, severe treatment, etc.), balanitis may follow, and 
in rare cases there may result ulcerations simulating soft 
chancre, with inflammation of the inguinal glands. One 
attack of this affection predisposes to others, so that it 
is commonly recurrent, appearing periodically or at 
irregular intervals for months or for years. The persist- 
ency with which this simple disorder recurs is not only 
annoying but also peculiarly distressing when in conse- 
quence patients believe themselves to be subjects of 
syphilis. In the hands of the ignorant or the unscrupu- 
lous these deluded victims often undergo specific treat- 
ment for long periods. 

Diagnosis. — The excoriations of herpes can usually 
be distinguished from those of balanitis by the circular 
outline of the herpetic lesions, which is rarely entirely 
lost even when the vesicles have coalesced, and by the 



346 SYPHILIS AND THE VENEREAL DISEASES, 

absence of more extended inflammation. When the ex- 
coriations suppurate and form superficial ulcers, it may 
be impossible to distinguish them from beginning chan- 
croid, but by cleansing the parts and keeping them 
covered with iodoform or aristol herpetic ulcers will at 
once begin to improve, and in a few days will be 
entirely healed. An initial sclerosis may appear as a 
small excoriation, but underlying induration can be de- 
tected ; the sore is indolent, and is soon accompanied by 
characteristic enlargement of the inguinal glands. In 
making a prognosis it must be remembered that chancre 
may follow in the site of an herpetic lesion if the longest 
period of incubation of syphilitic chancre has not elapsed 
between the date of exposure and that of the examina- 
tion. 

Treatment. — The local treatment of herpes progeni- 
talis is that of balanitis. Recurrences may often be 
avoided by improvement of the general health and by 
hygienic living, including abstinence from alcohol, 
tobacco, and highly seasoned food. In obstinate cases 
the surface of the glans and prepuce may be hardened 
by the long-continued use of tannic acid in powder or in 
solution of water and alcohol. 



HYPOCHONDRIASIS. 



The morbid mental states produced by real or fancied 
venereal disease are numerous, and are equalled only 
by the hypochondriasis springing from ignorance and 
perversion of the physiological functions of the sexual 
organs. These morbid mental conditions are of occur- 
rence in both sexes, far more frequently in men than in 
women, the subjects being generally near the puberal 
epoch. The symptoms presented differ in grade of 
severity, and when of marked character they may result 
in more physical distress than the maladies themselves, 
of which there is either slight evidence or a mere dread. 
For practical purposes the sexual hypochondriac and 
the patient in terror of a venereal disease, actual, 
possible, or wholly imaginary, may be considered in the 
same category. 

It is a matter of common remark that the physiology 
of the generative organs of the male sex is less under- 
stood by the average physician than that of the corre- 
sponding functions in women. In the management of 
the youths, commonly unmarried, who are sufferers from 
the mental states here considered, it is important to re- 
call the following facts : 

Among the mammalia of the lower animals the sexual 
propensity is in general gratified with impunity in pro- 
miscuous relations, the young males copulating with in- 

347 



34^ SYPHILIS AND THE VENEREAL DISEASES. 

dividuals of the other sex freely on the earliest impulse, 
when not restrained by stronger adult males and by 
females who are not ready to accept approaches. 
From this event dates the sexual life of the animal, the 
male, when no longer capable of performing the sexual 
act, being often killed by stronger and more ambitious 
rivals or being abandoned to die apart from the group 
of breeding animals. Throughout this sexual life the 
male animal has, in the state of nature, no seminal emis- 
sions and no perversion of controlling sexual instinct. 
As a rule, he refuses to solicit the female of his kind 
when she is pregnant. In many cases the period of 
activity of the sexual impulse of the female corresponds 
with that of the other sex, and beyond that season the 
two often exist together in a harmonious asexual life. 
Obviously, this arrangement is designed solely with the 
view of reproducing the species. 

The female, as a rule impregnated at the earliest 
ovulation, begins with this event a sexual life which 
thereafter consists of a series of pregnancies and suck- 
lings of offspring until she is incapable of further concep- 
tion, when she also either dies or is killed, having 
fulfilled her part in the struggle for existence. There 
is no history of menstruation — a function which, with its 
important accessory phenomena in generations of trans- 
mitted tendencies, distinguishes the female of man alone 
in the animal creation. 

When man is studied in his artificial social surround- 
ings, he is seen at once to be amply fitted for the 
part he is to play in life of a broader scope and deeper 
intent than that of the brutes. The young human 
male is required by the written and unwritten laws 
of most civilized countries to deny himself the grati- 



HYPOCHONDRIASIS. 349 

fication of his sexual appetite until he is capable 
of union with one woman and of providing for the 
support of a family. During the time which intervenes 
between the attainment of puberty and marriage there 
is a period of unrest, and in many cases even of physi- 
ological storms which ever and again disturb the tenor 
of his days. If he happens to be among the large 
number of lads who early in life have practised mastur- 
bation, a perusal of the advertisements of the charlatan, 
with their record of horrors, may awaken in his breast a 
dread of a frightful future. He comes to his physician 
or friend (well for him if the former be also the latter) 
with a tale of involuntary seminal emissions at night, 
with and without erection ; an escape of semen when 
straining at stool ; " lost manhood ; " defective memory ; 
spots dancing before the eyes; "impotence;" sexual 
debility ; general weakness ; and disinclination for 
society. 

With the trained physician it is scarcely necessary to 
discuss this group of " symptoms." Involuntary noc- 
turnal discharges of semen occurring in a young man 
several times during one night, or even on successive 
nights, are " unnatural " simply because the human male 
animal is not living in the state of nature briefly sketched 
above. These losses are of similar import whether 
occurring with erection and accompanied by a lascivious 
dream, or in the total unconsciousness of sleep. They 
are truly physiological, and amount to the price paid by 
the youth who is attempting to lead a correct life and 
who refuses to lower his moral standard. The frequency 
of these discharges has little bearing upon any question of 
disease, since in perfectly sound youths seminal losses may 
be even often repeated without detriment to the general 



350 SYPHILIS AND THE VENEREAL DISEASES. 

health. A frequency at one time is usually compensated 
for by a relative absence at another. The emissions may 
be followed on the succeeding day by a feeling of lassi- 
tude, slight frontal headache, and mental dulness, but the 
balance is always struck by nature, as there is usually 
afforded a respite from the sexual fever (if such it may 
be called), when the discharge or the series of successive 
discharges is at length for the time being made to cease. 
These losses wholly correspond in physiological function 
and meaning with the menstruation of the young woman, 
whose monthly flux in a sense represents the price paid 
by her for virginity, clean living, and a delay of the 
performance of the sexual function until she is solicited 
in marriage by an acceptable suitor. I4,^is true that, 
after marriage menstruation may occur periodically, but, 
as a rule, it is suspended during pregnancy. Married 
men also, temperately indulging in sexual relations, 
occasionally have periodical involuntary seminal losses. 
It is well known that the comeliness of a young girl is 
almost proportioned to the regularity and character of 
her monthly periods. None the less is it certain that 
the attractiveness of a youth leading a clean life — : 
that which makes the eye of man and woman dwell 
on his person with a sense of delight, the promise 
of manhood writ large on his features and figure — is 
to a degree proportioned to his involuntary losses at, 
night 

Nor is the periodicity observed in menstruation not 
perceptible in the corresponding function of the other 
sex, seeing that not only are married men at certain 
seasons of the month specially disposed to the gratifica- 
tion of sexual desire, but that the unmarried also, at 
certain times in the month more than at others, have an 



H YPOCHONDRTASIS. 3 5 1 

access of similar import. There is, in fact, a prostatic 
no less than a uterine ebb and flow of sexual congestion, 
and the reverse, that is responsible for many phe- 
nomena of health and disease perceptible in the two 
sexes and often wretchedly misinterpreted. Many, in- 
deed, of the " pollutions " of young men at night (sug- 
gesting the menstruation of women not accompanied 
by ovulation) are discharges largely made up of the 
prostatic fluid rather than of semen. 

Much the same explanation can be given of the 
" losses at stool " on straining which are such a bugbear 
to the uninitiated. These losses, too, are largely made up 
of the fluids of the prostatic sinuses, expressed by pres- 
sure upon the gland exerted by a scybalous mass in the 
rectum. There is no evidence whatever that this " loss 
at stool " is, in the life of any continent man, a sign of 
disease. Men differ greatly in the quantity of prostatic 
secretion they furnish, precisely as they differ in the 
amount of salivary fluid supplied during mastication. 
There is no fixed standard for all men, as there is 
none for the food they daily eat and for the amount of 
excreta they void as a consequence of the assimilation 
of portions of that food. Indeed, many married men, 
regularly and temperately gratified sexually, find a nota- 
ble quantity of the same glycerin-like secretion at the 
meatus urinarius after stool when the general health is 
absolutely unimpaired and their organs are in a normal 
state. The milky fluid seen by the sexual hypochon- 
driac when actually engaged in voiding urine is, as is 
well known, not seminal in character, but is due to the 
presence of the alkaline phosphates, and originates in 
conditions wholly apart from the sexual organs. The 
clearing up of this cloudiness by the addition of a small 



352 SYPHILIS AND THE VENEREAL DISEASES. 

quantity of acid in the presence of the sufferer is usually 
of value in restoring his mental equilibrium. 

At times the microscopical examination of the pros- 
tatic fluid exuded at stool, and even of the urine of the 
hypochondriac, reveals the presence of spermatozoa. 
Even here no evidence is presented that the person is 
the victim of disease. The spinal and other symptoms 
of true spermatorrhoea need not here be considered. As 
a morbid state it is unquestionably rare, and is not to be 
classed with the functional derangements of the puberal 
epoch and its sexual alternations of storm and calm. 

Masturbation may be prolific of serious physical mis- 
chief; but many of its results are exaggerated, and for 
the great majority of youths who discover the nastiness 
and indecency of the habit, and who abandon it, no 
serious consequences ensue. This is the verdict of con- 
servative and experienced physicians the world over. 
The worst of its results, for the majority of men, are 
mental — the sense of unmanliness, the loss of self- 
respect, and the dread of the future which it begets. 
The best recourse in this morbid mental state is a timely 
confession to a wise physician, the acceptance of some 
explanation of the physiological function of the sexual 
organs, and the receipt of a good deal of encouragement 
for the future. The youth should be informed clearly 
that during a young man's period of sexual probation 
he has a constant conflict to wage between his passions 
and his better self, from which conflict he should emerge 
a victor — if not wholly unscathed, at least like the soldier 
who has made a brave fight and has conquered, not 
without some resulting scars, the enemy that sought to 
vanquish him. The best of fathers and husbands are 
veterans of such conflicts. 



H YPOCHONDRIA SIS. 353 

" Impotency " is a condition of which a great number 
of men know nothing, however eloquently they may 
bewail its occurrence. Having suspected in themselves 
some weakness, they often attempt to perform the sexual 
act, chiefly with a view to experiment, and the novelty 
of the situation, the dread of failure, or the fear of con- 
tracting some disease has left them powerless ; or, 
possibly, when engaged in fondling and caressing a 
female companion they have experienced a flow either 
of the prostatic or of the seminal fluid itself, which has 
persuaded them beyond peradventure of a " sexual 
weakness " with which they are afflicted. 

The point of view for all questions of this order is 
that which regards equally the two sexes. The inex- 
perienced youth should be like the inexperienced girl in 
the first approaches after marriage — shrinking, tremb- 
ling, timid, and unprepared. It is estimated that from 
60 to 70 per cent, of young husbands fail in the first 
sexual attempts after marriage, and whatever figures 
may here represent the truth must surely be applicable 
to the other sex. The truth is, that while the young of 
the lower animals are early taught by experience to per- 
form the sexual act without dread and, in the wild 
state, for the most part without preference of individual, 
men and women reared in civilization and surrounded 
by the usual safeguards of social order require to 
mutually educate each other in the matter of physical 
union. Never is the sexual act so vigorously and effec- 
tively accomplished as when the strong emotion of love 
unites two human beings and elevates the performance 
of the brute to the level of a pure morality. Hence the 
complaints of " premature ejaculation of semen " and of 
" failure of erection " on the part of the hypochondriac 

23 



354 SYPHILIS AND THE VENEREAL DISEASES. 

have no meaning when interpreted in the Hght of 
science. 

The " lost manhood " of these fond youths is an echo 
from the outgivings of the parasites of the profession. 
Manhood in its best sense bears small proportion to the 
vigor and capabilities of the sexual organs. In so far 
as man is distinguishable from the brutes is he removed 
from their sexual habits and powers. The lower the 
individual in the scale of civilization, the more conspicu- 
ous, as a rule, is his sexual power and the number of 
resulting progeny. The negro, the Indian, and the half- 
breed are in this point widely removed from the highest 
types of the Anglo-Saxon. Even when in the grasp of 
disease, the tuberculous, the syphilitic, the leprous, the 
idiotic, and those burdened with the inherited and ac- 
quired maladies of the pauper fetch into the world their 
superfluous brood to be a burden to society and a re- 
proach to civilization ; while men and women far above 
them in the social scale, and superior alike in point of 
physical endurance and mental energy, perform the 
sexual act with far less inclination, frequency, and readi- 
ness. For some of the very noblest types of manhood 
and womanhood, indeed, indulgence in the sexual act is 
notably infrequent, the resulting offspring few, and the 
marriage state often unsought. 

The listlessness, loss of memory, muscae volitantes, 
and lack of physical energy cited by the hypochondriac 
as evidences of his condition are obvious misinterpreta- 
tions of the changes from day to day incidental to all 
active lives. The fatigue of nervous anxiety is not neces- 
sarily morbid. The memory of some of the insane is 
remarkably good ; it is a faculty conspicuously wanting 
among some of the greatest men of history, and in most 



HYPOCHONDRIASIS. 355 

persons is largely the result of their education and 
environment. 

" Impotence " is a word that for the expert has no 
longer a definite meaning. Every healthy adult male is, 
in the sense in which that word is popularly employed, 
both potent and impotent. Some men, like the negro, 
are capable of committing a rape as often as the 
occasion offers, merely to gratify lust ; fortunately, they 
are few and usually meet with a violent end. Fortu- 
nately, also, the best type of man, living a clean life, is 
wholly unable to perform the sexual act save with the 
one woman in the world whose life is devoted to him 
alone. For the men within these two extremes a 
thousand accidents — disgust, anger, excessive bodily or 
mental fatigue, recent evacuation of the seminal vesicles, 
and who can say what else — daily render them " im- 
potent" in the sense in vv^hich this word is often used. 

Nor is the man who, living a clean life, chances to 
possess unusual sexual vigor, for this reason to be set 
down as a type of superb manhood. With infinite fore- 
casting of the needs of the race, it is ordered that the 
sexual propensity be most eager, most energetic, and 
most effective in exercise at an early period of life, when 
the real vigor of a man, mental and physical, is actually 
immature. Obviously, all is planned with a view, first, 
to the perpetuation of the race, and, after that, to pro- 
vision for the young of the family under the shelter of 
the roof reared by the strong hand and provided with 
sustenance by the experienced brain of the maturer 
man. 

When the sexual hypochondriac oversteps the limits 
here set — those, namely, within which a fairly healthy 
youth passes through his period of sexual probation, 



356 SYPHILIS AND THE VENEREAL DISEASES. 

with a heart saddened and perhaps affrighted by the 
ghosts that beset his pathway — then he enters a patho- 
logical field which cannot be named without a sense of 
disgust. The unnatural practices which the records of 
history teach are as old as the Saturnalia of the Roman 
Empire, prevail only to a limited extent in our own day. 
Alienists, chiefly those connected with state institutions 
for the care of the insane, have probed the depths of 
this vileness, and with scientific precision have analyzed 
the symptoms of sexual psychopathy as they are be- 
trayed in masochism, sadism, tribadism, sapphism, 
pederasty, sodomy, bestiality, erotomania, and satyriasis. 

To the credit of humanity it may be added that these 
habits are often manifestations of insanity due to lesions 
of the nervous centres. The victims of these disorders 
are the frequent subjects of epilepsy, imbecility, or 
dementia, and often exhibit microcephalic, asymmetrical, 
or scar-compressed crania. 

Syphilophobia is a term used to describe the con- 
dition in which patients become morbidly terror-stricken 
over the possibility of having incurred syphilis. The 
term may be used, if not with accuracy, at least usefully, 
to include those who are morbidly anxious lest any 
of the venereal diseases other than syphilis, such as 
gonorrhoea, have been incurred. It matters not what 
be the object of terror, the mental state is practically 
the same. 

It is seldom that in the venereal diseases any more 
wretched complexus of symptoms is presented than in 
a well-marked case of syphilophobia. The weird of 
the thing seizes alike on men and women, and while it 
endures, life is usually embittered, the happiness of a 
home often blighted, and the body wasted under the ner- 



HYPOCHONDRIASIS. 357 

vous strain. Sleep, digestion, nutrition, and peace of mind 
vanish ; the tongue becomes dry, the eyes haggard, the 
person neglected. From this extreme there is every 
gradation to the other, where there is simply a short- 
Hved and happily-ended anxiety. Only an abounding 
selfishness can impel men to these conditions, but many 
patients claim that their unending terror is based on 
apprehensions for another — a wife, a betrothed, a 
daughter, a sister, a husband, or a friend. This con- 
dition may endure for but a few days or weeks, or it 
may last for years. It may even be for a long while 
shared in full measure by a consort. In a few cases we 
have seen men and women go insane under the burden 
of the anxiety. In these extreme instances it may well 
be believed that the insanity was lingering unrecognized 
until the accident suggesting fear of venereal disease be- 
came the immediate and exciting cause of the disaster. 

The bases of the suspicions of these people are widely 
different. Some individuals exhibit tangible lesions of 
the surface, which they choose to misinterpret, after a real 
or fancied exposure to venereal disease. Thus a facial 
acne, a keratosis pilaris of the outer faces of the thighs 
and arms, a telangiectasis (" spider cancer ") of the 
surface of the chest, some innocent mollusca of the 
scrotum, or a few aphthous ulcers of the mouth due to 
indigestion, serve as unmistakable signs of syphilis. 
Often in their restless anxiety these victims swallow 
medicaments with a view to eradicating the malady with 
which they are convinced they are infected, and these 
drugs, by the production of a medicamentous rash, add 
to the supposed evidences of disease. 

When no lesions are present on which to build these 
anxieties, a basis is readily discovered in the anatomical 



358 SYPHILIS AND THE VENEREAL DISEASES. 

peculiarities of the body. In this way the bluish tinge 
at the rim of the corona glandis is taken to be a sign 
of " gangrene ; " the fungiform papillae of the tongue 
are named as *' mucous patches;" the reddish hue of 
the meatus externus urinarius indicates " inflammation." 
In some cases the testicles are too closely drawn up to 
the body ; in others they are too lax ; in yet others the 
penis is shrinking; in women the vulva is beset with 
"papules " when its follicles are unusually conspicuous. 
If these unfortunates once become possessed of works 
on medicine, they are usually worse distraught. It is 
not at all surprising that even classical illustrations of 
this singular craze are furnished in the persons of physi- 
cians themselves. The subject, even though it seem to 
have a ludicrous side, is not without its tragic aspects. 
We have known men to take their lives in despondency 
over such fancied disorder. The trained physician must 
be ready to appreciate every phase of the madness. 

The treatment of the several forms of hypochondriasis 
described requires the utmost skill, prudence, and good 
judgment on the part of the physician. The chief 
remedy at hand is a knowledge of the truth. This 
alone is often sufficient. A common-sense explanation 
and a little encouragement often suffice to remove a 
persistent cloud of shame and dread. Unfortunately, 
as the history of the world clearly proves, men and 
women will not always listen to the truth. Sympathy 
does good at times ; at others it is worse than useless, 
and ridicule, even scolding, may answer the end better. 
For the obstinate subjects who refuse all aid of this 
character and persist in retailing their long list of symp- 
toms to the ear of the physician, he may even make 
shift to accomplish his end by wholesome threats. It 



HYPOCHONDRIASIS. 359 

may be wise in cases to point to the idiotic condition 
that occasionally crowns a labor of the sort upon which 
the hypochondriac is engaged, or even, as a last resort, 
to make it appear that, since the patient will listen to 
neither truth nor reason, his friends must be made 
acquainted with the facts in his case. The last is often 
an effective argument. It is a pitiable fact that some 
of these states are utterly hopeless. The patients either 
belong to the insane class or are of those of whom it 
was long since written that even brayed in a mortar 
their folly will not depart from them. 

For the young male sexual hypochondriac important 
advice touches his moral surroundings ; but over and 
above this he should be made to abandon tobacco and 
alcohol, to employ the flesh-brush after his cool morn- 
ing bath, to avoid hot and Turkish baths, and even cold 
bathing at night, which is apt to be followed by undue 
stimulation when he is well warmed in bed. His food 
should be nutritious and simple. It is a common error 
for these young persons to attempt living on a slim diet 
to avoid stimulating the sexual propensity. All medi- 
cines of the sort commonly given to allay nervous ex- 
citability, such as bromide of potassium, are rigidly to 
be excluded. For these subjects they are vile remedies, 
and they exert an injurious effect upon the mental tone 
of the person who relies upon them. From a scientific 
point of view, they are given with a wholly false con- 
ception of the end to be attained. The bowels should 
be evacuated daily, and there should be open-air living 
and physical exercise. The dance, theatrical perform- 
ances, club life, and the perusal of certain kinds of liter- 
ature are equally harmful. To persons of this class 
medical books are to be especially prohibited. 



ACUTE URETHRITIS. 



The term " urethritis " includes all forms of urethral 
inflammation. By far the most common of these inflam- 
mations is gonorrhoea. Cases of urethritis originating 
without the influence, direct or indirect, of gonorrhoeal 
infection are rare. Other forms of urethritis, arising 
from constitutional defects or from mechanical or 
chemical injury to the urethral membrane, occur, but 
they are chiefly interesting from the standpoint of 
etiology, since in symptoms and treatment they corre- 
spond with some of the stages of the more common dis- 
order. In the following pages, except where mention 
is made of other forms of urethritis or of the disease 
as it occurs in women, the subject under consideration 
is gonorrhoea in the male. 

Etiology. — From an etiological standpoint, the best 
classification is that of Lustgarten, who recognizes two 
classes — infectious urethritis (including gonorrhoea, 
pseudo-gonorrhcea, syphilitic urethritis, and urethritis 
tuberculosa) and non-infectious urethritis. 

I. Infectious Urethritis. — i. Gonorr]i(£a {youyj, 
semen, and ^sTv, to flow). — Synonyms : Urethritis ; Clap; 
Blennorrhagia ; Blennorrhoea ; Gleet ; Germ. Tripper ; 
Schleimfluss ; Unreiner Fluss ; Gonorrhoe ; Fr. Blen- 
norhagie ; Gonorrhee ; Chaudepisse ; Span, and Ital. 
Gonorrea. 

The term " gonorrhoea " is a misnomer, but it has 

360 



ACUTE URETHRITIS. 36 1 

been so long employed in a specific sense that it must 
be retained for the present rather than be supplanted 
by one more scientific. In these pages its use is 
restricted to indicate that acute, infectious form of 
urethritis which follows a period of incubation, pursues 
a more or less definite course, and produces a discharge 
which contains gonococci and is capable of causing a 
like form of inflammation in the mucous membrane of 
the healthy urethra of another individual. Of all 
diseases, gonorrhoea is the most correctly termed 
venereal, for it most frequently results from sexual 
intercourse, and is rarely acquired in any other way. 
Simple contact of a gonorrhoea! discharge with the 
mucous membrane is sufficient in the large majority 
of cases to communicate the disease, though the vagina 
is less easily infected than the urethra, and some persons, 
particularly under special circumstances, are less suscep- 
tible than others. The general condition of the indi- 
vidual, the state of the mucous membrane exposed to 
infection, and the circumstances of the exposure, other 
than the presence of a gonorrhoea! discharge, play a 
much less important part than in the other venereal 
disorders. A man who exposes his urethra to a gonor- 
rhoea! discharge has few chances of escaping infection. 
On the other hand, since the source of contagion lies 
solely in the discharge from the diseased membrane, 
and does not exist in the blood and in special secretions 
of the body, as in syphilis, the opportunities for acquir- 
ing gonorrhoea outside the sexual act are rare. It must 
not be forgotten, however, that gonorrhoea may be in- 
nocently acquired, and that it is possible for the con- 
tagion to be conveyed by means of a towel, the seat 
of a public water-closet, and other media. 



362 SYPHILIS AND THE VENEREAL DISEASES. 

The Goiiococcus. — It is now generally conceded that 
the active factor in the production of gonorrhoea is 
the gonococcus of Neisser. This micro-organism is 
found in the purulent discharge of acute urethritis, 
known as gonorrhoea ; in the muco-purulent discharge 
and threads (tripper fadeii) of certain chronic and sub- 
acute forms of urethritis ; in the gonorrhoeal discharges 
from the vagina, uterus, conjunctiva, and rectum; and 
a few cases have been recorded in which gonococci were 
found in the secretion of the mucous membrane of the 
mouth and the nose. This micro-organism has also 
been found in joints affected with gonorrhoeal rheu- 
matism, in periurethral folliculitis and abscesses, and in 
suppurating vulvo-vaginal glands. Bumm, Wertheim, 
and others have repeatedly succeeded in cultivating the 
gonococcus, and by inoculating the healthy urethra 
with these cultures have produced an acute urethritis 
having an incubation period of from two to five days 
and a duration of five or six weeks, the discharge con- 
taining gonococci. In one instance the twentieth gen- 
eration of a pure culture was thus successfully employed. 
These experiments seem to demonstrate fully the patho- 
genic character of this micro-organism. It should be 
remembered, however, that even the normal urethra 
may be inhabited by one or more species of diplococci, 
which so closely resemble the gonococcus in all partic- 
ulars, including staining properties, that the most expert 
cannot always differentiate them with certainty. 

[a) Preparation and Examination of the Specimen. — In 
selecting gonorrhoeal pus for examination it is well to 
avoid that found at the meatus, as this pus is more 
liable to contain other organisms that might render the 
examination complicated and confusing. It is better to 



URETHRITIS. 



Plate 8. 




I. Gonococci in gonorrhceal pus; X500 (from a photomicrograph by Dr. John A. Fordyce). 
2. Gonococcus (after Bumm) : a, from a pure culture; />, secretion from a gonorrhceal conjunc- 
tivitis, showing an epithelial cell partially covered with gonococci ; three pus-cells, two of which 
contain gonococci ; and a group of three gonococci ; c, division and multiplication of gonococci 
(schematic). 



ACUTE URETHRITIS. 363 

obtain pus that may be squeezed out of a deeper portion 
of the urethra. A small drop of this pus is thinly 
spread on a slide or a cover-glass, by means of a plat- 
inum wire or by pressing the drop between two cover- 
glasses and then slipping them apart. The thin film is 
allowed to dry in the air, and is then fastened to the 
glass by slowly passing it three times through the tip 
of the flame of an alcohol lamp or a Bunsen burner, 
the pus-covered side being upward. The film is then 
covered with a few drops of the staining fluid, or the 
cover-glass is floated, film side down, on the liquid. 
The preparation should remain in the stain from one to 
five minutes, depending upon the strength of the solu- 
tion, after which the surplus stain is gently washed off 
with a jet of cold water. The specimen can now be 
examined in water or in glycerin, or, what is better, it 
can be dried carefully with soft blotting-paper and 
mounted in Canada balsam. 

The stain employed may be almost any of the basic 
aniline dyes, as methyl-blue, Victoria blue, methyl-violet, 
gentian-violet, or fuchsin. These dyes may be used in 
aqueous solutions of varying strength, but they do not 
keep well, and it is best to prepare the fluid each time 
it is wanted. This may easily be done by keeping on 
hand a saturated alcoholic solution of the stain, a very 
small quantity of which can be added, drop by drop, to 
a watch-glassful of distilled water until the latter is of 
the required strength and color. The following is a 
rapid and satisfactory method : A solution of methyl- 
blue is prepared by dropping a saturated alcoholic solu- 
tion of the stain into a watch-glassful of distilled water or 
into a solution of potassium hydrate (i : 10,000) until the 
liquid has a dark-blue color. The cover-glass, prepared 



364 SYPHILIS AND THE VENEREAL DISEASES. 

in accordance with the above directions, is floated on 
this Hquid, pus side down, for from one to two minutes ; 
it is then taken out and the surplus stain is washed off. 
It may now be placed at once, without drying, upon a 
slide and examined, or it may be carefully dried and 
mounted on a slide with Canada balsam. In a specimen 
thus prepared the gonococci appear dark blue, while the 
cells show a very pale blue protoplasm and grayish-blue 
nuclei. 

The gonococci are readily decolorized by acids or 
by alcohol as in Gram's method. In doubtful cases the 
last-named method is claimed to be capable of making 
the diagnosis a certainty, but it has been pretty well 
demonstrated that a few other diplococci lose their stain 
in exactly the same manner as do the gonococci, and 
that even this test cannot always be relied upon. The 
method is as follows : 

1. Prepare cover-glass as above described. 

2. Stain for from two to five minutes in a saturated 
solution of gentian-violet in aniline-water. (Aniline- 
water is prepared by adding 5 parts of aniline oil to 1 00 
parts of water and shaking thoroughly. The milky 
fluid thus produced is filtered until it comes through 
clear and transparent To this fluid a saturated alco- 
holic solution of the stain is added, drop by drop, until 
the liquid loses its transparency and a distinct opales- 
cence results.) 

3. Place the preparation for from one to one and a 
half minutes in iodine solution (iodine i part, potassium 
iodide 2 parts, water 300 parts). In this solution the 
preparation becomes quite black. 

4. Place in alcohol, and allow to remain until no more 
color is extracted. 



ACUTE URETHRITIS. 365 

5. Wash in distilled water. 

6. Stain for half a minute in a weak solution of Bis- 
marck brown. 

7. Wash in distilled water. 

8. Dry and mount in Canada balsam. 

The gonococci and a few other diplococci lose their 
blue stain by this method and take a brown stain. 
Such diplococci as retain the blue stain are not gono- 
cocci. 

F'or a satisfactory examination of the preparation, 
good lenses, with a magnifying power of at least 500 
diameters, and a substage condenser should be em- 
ployed, an immersion lens being always desirable, and 
in doubtful cases usually necessary. 

(8) Characters. — Each single gonococcus has a shape 
much like that of a kidney or a coffee-bean ; but, like 
other diplococci, these organisms appear in pairs. Each 
pair is thus made up of two individuals so placed that 
the flattened surfaces face each other, but are separated 
by a narrow space, which in the stained specimen appears 
as a clear (unstained) line (PL 8). In the process of 
reproduction each individual divides into two, the divid- 
ing-line being at right angles to the flattened surface. 
The result is two pairs instead of one, and the usual 
grouping of the gonococcus is explained, for it is found 
rarely in chains, but usually in clumps of four or multi- 
ples of four. The micro-organism is seen not only be- 
tween and upon the epithelial cells and pus-cells, but 
also within the latter. This position in the pus-cell is 
characteristic of the gonococcus, and possibly of a few 
other rarer forms of diplococci, and is determined by 
observing that the micro-organisms are in focus at the 
same time with the nucleus and outlines of the cell, and 



366 SYPHILIS AND THE VENEREAL DISEASES. 

by noting that, though a pus-cell may be filled with 
gonococci even to its border, they rarely, if ever, project 
beyond it, as would frequently be the case if they were 
simply lying on the surface. A cell may contain a 
single group, or so many as to conceal the nucleus or 
finally to burst the cell-wall, allowing the groups of 
gonococci to escape. 

Until recently, culture of the gonococcus has been 
unsuccessful except on human blood-serum. Wertheim 
used culture-plates according to Koch's method, made 
with I part of human blood-serum and i or 2 parts of 
peptone, agar, or gelatin solution. His cultures were 
easily made and grew rapidly. Finger recommends a 
culture-medium composed of urine and agar, i part of 
the former to 2 of the latter. He finds that the gono- 
cocci do not grow well in a strongly alkaline medium, 
and that a temperature of 40° C. (104° F.) will destroy 
them if continued a number of hours. 

(c) Value in DiagJiosis. — The characteristics of the 
gonococci that distinguish them from other diplococci 
are their shape, their grouping in fours or multiples of 
four, their position in, as well as on and outside of, the 
cell, and their staining properties, including especially the 
readiness with which they lose their stain when treated 
with alcohol. When diplococci possessing these charac- 
teristics are present in large numbers, there is no doubt 
that they are gonococci ; but there have been found in 
urethral discharges diplococci which possess all these 
characteristics, but which yet are not capable of produc- 
ing a gonorrhoea. They are, however, not common, are 
never present in large numbers, as is the rule with gono- 
cocci, and are usually associated with a larger number of 
other micro-organisms common to the urethra. They are 



ACUTE URETHRITIS. 367 

probably present, and liable to be a source of error in 
diagnosis, in about 5 per cent, of all cases. Some 
believe this percentage should be much larger. The 
question is plainly a most difficult one to decide, since 
the only method yet found of making the differential 
diagnosis with absolute certainty lies in culture- and 
inoculation-experiments. These methods must have a 
narrow range of application, since the cultivation of the 
gonococcus is too laborious and difficult to be carried 
out in every case or by anyone but an expert; while 
inoculation is practically out of the question, since man 
is the only animal yet clearly proven to be susceptible 
to the disease. 

The three following facts have been demonstrated 
clearly: i. Gonorrhoeal pus, or a pure culture of gono- 
cocci from such pus, produces gonorrhoea. 2. Pus free 
from gonococci, or a pure culture of micro-organisms 
found in such pus, does not produce gonorrhoea. 3. A 
slight subacute or chronic discharge containing a small 
number of gonococci may produce a true gonorrhoea; 
but a discharge of apparently the same nature, and con- 
taining diplococci that cannot be differentiated from 
gonococci, often fails to produce an infection of any 
kind. 

In all cases of acute urethritis it is evident that the 
microscope is of great value in making a diagnosis, for 
the discovery of gonococci in the discharge at once 
decides it to be a gonorrhoea and infectious in nature (its 
immediate origin is not necessarily infectious ; see 
Bastard Gonorrhcea), while an acute discharge that after 
repeated and thorough examinations on several succes- 
sive days fails to show gonococci may safely be pro- 
nounced non-gonorrhoeal. In a large class of subacute 



368 SYPHILIS AND THE VENEREAL DISEASES. 

and chronic forms of urethritis the microscope renders 
valuable service, but often by its use alone the diagnosis 
cannot exactly be determined, and one must then rely 
largely on clinical conditions and experience to decide 
upon the infectious or non-infectious nature of the case 
in hand. 

2. Pseudo-gonorrhcea. — A few cases are reported in 
which micro-organisms other than gonococci were ap- 
parently responsible for urethritis closely resembling a 
gonorrhoea, and in which culture- and inoculation-experi- 
ments were made by competent observers. These cases 
are rare, and not yet sufficiently understood to call for 
special consideration by the general practitioner. 

3. Syphilitic UrethiHtis. — During the early stages of 
syphilis mucous patches may form in the urethra and be 
the source of a scarcely noticeable discharge. In a 
patient under treatment for recognized syphilis such a 
discharge is of little importance and calls for no special 
treatment or precautions, as it is assumed that no physi- 
cian will allow a patient whom he is treating for syphilis 
to indulge in sexual intercourse. In unrecognized cases 
such a discharge might prove a source of infection. 
Further, a urethral chancre may furnish a discharge 
closely resembling that of gonorrhoea, and this mistake 
in diagnosis is frequently made as the result of careless 
examination. Manipulation of the parts should reveal 
the presence of the sclerosis. 

4. Urethritis Tuberculosa. — Primary tuberculosis of 
the urethra has been reported in rare instances. It 
occasionally occurs in the form of ulceration in general- 
ized tuberculosis of the genito-urinary tract. The dis- 
charge from the urethra should show tubercle bacilli. 
The examination must be conducted with great care, 



ACUTE URETHRITIS. 369 

and special methods must be employed, otherwise the 
smegma bacilli and other micro-organisms found in the 
urethra and in the urine will lead to confusion and error. 

II. Non-infectious Urethritis. — A mild or even a 
violent urethritis may follow mechanical or chemical 
violence to the urethra. It is difPcult to decide how 
often the cause of these apparently frequent cases lies 
solely in the urethral injury, since other causes, on care- 
ful investigation, are often disclosed. The commonest 
source of error lies in the fact that a urethra damaged 
by a previous gonorrhoea may show no evidence of its 
diseased condition until it becomes the seat of urethritis 
as the result of an irritation that would have no effect 
upon a perfectly sound urethra. Some individuals of a 
strumous or gouty diathesis seem prone to urethritis on 
comparatively slight provocation, such as the passage of 
highly acrid urine, indulgence in beer or alcohol in any 
form, or ungratified sexual excitement. In the majority 
of these cases, however, there is a history of true 
gonorrhoea at some time in the past. Somewhere in 
such a urethra there probably has existed an area of 
congestion or thickening or a forming stricture. Those 
forms of urethritis due to syphilis and to tuberculosis 
have already been mentioned. But while a diathesis is 
frequently responsible for the readiness with which some 
men acquire the disease, and while the systemic condi- 
tion often exerts a most important influence upon the 
course and duration of the local process, in the vast 
majority of cases the production of urethral inflamma- 
tion requires the presence of an irritant acting locally. 

Mechanical violence may produce an inflammation of 
a urethra that has previously been sound. This form 
of urethritis follows the improper use of sounds and 
24 



370 SYPHILIS AND THE VENEREAL DISEASES. 

other instruments by unskilled or careless operators, the 
introduction by the patient of foreign bodies into the 
urethra or the bladder, and occasionally the passage of 
fragments of calculi from the bladder. This form of 
urethritis usually develops within a few hours after the 
violence is done ; its intensity is in direct proportion to 
the amount of mechanical damage inflicted upon the 
mucous membrane, and it generally disappears promptly 
on removing the cause, without further treatment than is 
necessary to keep the urine bland and unirritating to the 
injured surface. 

CJiemical violence, resulting from the use of too strong 
injections, from irritating vaginal secretions, from the 
internal use of cantharides, and possibly from too great 
concentration of the urine, may produce urethritis in 
varying degrees of severity. Here, again, the symptoms 
come on promptly without any period of incubation, 
and, as a rule, the cause having been removed, disappear 
rapidly under very simple treatment. 

With these forms of urethral inflammation should be 
considered the cases of urethritis caused by irritating 
vaginal secretions and discharges in women in whom 
no trace of gonorrhoea can be recognized on examina- 
tion. That some men under favorable circumstances 
do thus acquire a urethritis is unquestionably true. 
On the other hand, a married man who has had no 
previous disease of the urethra, who is otherwise well, 
and who is indulging in no sexual excesses, rarely 
acquires a urethritis from his wife, even though she have 
a leucorrhoeal or menstrual flux. Even the discharges 
from a carcinoma of the uterine neck or from a tuber- 
culous ulcer usually fail to injure the urethra of the 
husband. It would seem that these discharges are 



ACUTE URETHRITIS. 37 1 

capable of causing urethritis only when there is a pre- 
viously diseased urethra, a strumous diathesis, a debili- 
tated condition of the body, prolonged sexual excite- 
ment, excesses in coitus, or, as most frequently happens, 
a combination of several of the conditions named. 

Clinical experience shows that a woman, wife or mis- 
tress, may be incapable of giving urethritis to husband 
or lover, while a stranger may promptly acquire the 
disease in a single coitus with her. This is cited as proof 
of the so-called " acclimatization " of which Ricord and 
other writers speak. Not infrequently a newly-married 
man consults his physician for a mild or even violent 
urethritis, in great alarm lest his really innocent wife be 
not pure. If his urethra was previously sound (in the 
majority of such cases the man has had a gonorrhoea at 
some previous time), it is probable that his wife has 
leucorrhoea, or both have disregarded the beginning or 
the end of the menstrual flux, besides indulging to ex- 
cess, possibly after partaking of alcoholic or other stimu- 
lating articles of food and drink. Such a urethritis sub- 
sides in a few days under simple treatment, and if in the 
future their sexual relations are properly regulated, the 
husband will in all probability remain free from any 
future attack. 

It is in this class of cases that the tact as well as the 
skill of the physician is severely tested. He will be 
asked innumerable questions, and upon his answers may 
depend the integrity and future domestic relations of an 
entire household. It is far better to let the guilty escape, 
or to permit a patient to think that a successful im- 
position has been practised upon his physician, than 
falsely to accuse the innocent. With this end in view 
he will bear in mind the following facts : 



l^Jl SYPHILIS AND THE VENEREAL DISEASES. 

1. A healthy man with a sound urethra in all proba- 
bility cannot acquire a urethritis from a healthy woman, 
even if he indulge to excess. 

2. A healthy man with a sound urethra does not, as 
a rule, acquire a urethritis from a woman with vaginal 
secretions or discharges which are not gonorrhoeal. To 
this rule, however, clinical experience furnishes some 
undoubted, and many apparent, exceptions. 

3. There are instances in which a man of strumous, 
gouty, or tubercular diathesis, or with a debilitated 
general system, may acquire a mild form of urethritis 
from a healthy woman, particularly if sexual excesses 
with her be accompanied by other excesses, as at table. 
If the woman, instead of being healthy, has a leucorrhoea, 
urethritis follows more frequently and may be severe in 
type. 

4. There are many men with a slightly damaged 
urethra, the only evidence of which may be a drop or 
two of muco-purulent discharge at the meatus in the 
morning, or the presence of small threads of pus in the 
urine, or, indeed, with no apparent symptoms, who are 
ready to light up anew a urethritis as a result of 
any of the causes above named. Slight disturbances of 
the general economy (such as bronchitis, constipation, 
or diarrhoea), the excessive use of tobacco, beer, or 
alcohol, violent exercise, and great fatigue sometimes 
suffice without sexual excitement for such relapses; 
while sexual indulgences of any nature are almost cer- 
tain to be followed by a reappearance of the old trouble. 
These are cases of so-called bastard gonorrJicEa. They 
are generally subacute in type from beginning to end, and 
may present no other symptoms than a slight discharge, 
with possibly moderate itching at the meatus. They 



ACUTE URETHRITIS. 373 

usually run a short course, but they may be protracted, 
and if the irritation be sufficiently violent they may 
present any degree of inflammation up to that found in 
cronorrhoea. These cases are non-infectious in their im- 
mediate origin ; but if, as is often true, gonococci were 
still present in such a damaged urethra, they may multi- 
ply under the added inflammation, and a true gonor- 
rhoea, generally subacute, may result. 

5. A woman may have a true gonorrhoea which the 
examining physician is unable to detect. This is espe- 
cially true if the disease be limited to the urethra, and 
the acute stage, with swelling and redness of the parts, 
has passed ; or, again, if there be left only a chronic and 
subacute inflammation of the vulvo-vaginal glands. 
Noeggerath and others have proved beyond dispute 
that the Fallopian tubes, the uterus, and the cervix uteri 
may be the seat of a true gonorrhoeal inflammation and 
yet present no evidence that can be detected in a most 
careful examination of the external genitals and vagina. 
In the face of such evidence it is surprising that some 
physicians are willing, after examining public women, to 
give them a certificate to the effect that they have no 
venereal disease. Ninety per cent, of all pelvic diseases 
in women have their origin, it is claimed, in gonorrhoea. 
From coitus with a woman having one of these unrecog- 
nized forms of gonorrhoea some men will escape, while 
others will acquire the disease. 

6. The non-infectious forms of urethritis have no 
period of incubation, as in gonorrhoea, but promptly fol- 
low the operation of the exciting cause. They tend to 
a rapid recovery upon the removal of that cause, and are 
usually mild in type as compared with gonorrhoea, 
though they may exhibit a severe grade of inflamma- 



374 SYPHILIS AND THE VENEREAL DLSEASES. 

tion, and, rarely, be protracted in course and clinically 
indistinguishable from true gonorrhoea. The microscope 
shows no gonococci. 

Symptoms. — As a matter of convenience in descrip- 
tion, the course of gonorrhoea is here studied in suc- 
cessive stages ; these stages are not, however, always 
definite in duration or sharply defined one from the 
other. 

I. Stage of Incubation. — At the time of infection the 
virus is conveyed to the sound membrane in a very 
small quantit)' — too small to cause immediately a per- 
ceptible irritation — and it is not until the gonococci have 
developed and multiplied that they or their products, or 
both, produce a visible disturbance in their new habitat. 
The time required for this development varies from one 
to fourteen days, but in fully two-thirds of all cases it is 
from five to seven days. This wide variation is undoubt- 
edly due in part to the degree of virulence of the par- 
ticular virus, to the character of the soil upon which it 
is implanted, and to other circumstances attending its 
inoculation ; but the characteristics of the individual also 
play an important part. A highly sensitive man, and, in 
particular, one who is fearing and carefully watching for 
the result of an exposure, will detect the earliest slight 
symptoms, which would pass unnoticed by the average 
man ; while among the careless and uncleanly the dis- 
charge may become pronounced before attention is 
directed to it. 

When unmistakable symptoms appear before the 
third day, careful inquiry will usually elicit a history of 
more or less recent gonorrhoea from which the patient 
has really never fully recovered, though he may have 
supposed himself well. The case is then one of bastard 



ACUTE URETHRITIS. 375 

gonorrhoea. In simple urethritis the period of incuba- 
tion is wanting or is of only a few hours' duration. 

2. Beginning or Prodromal Stage. — The stage of in- 
cubation may be said to end, and the prodromal stage 
to begin, when the patient first notices, especially on 
urinating, a slight teasing, pricking, tickling, or uneasy 
sensation at the meatus urinarius. On examination 
the lips of the meatus may be slightly red, or, if the 
patient has not urinated for some time, they may be 
slightly stuck together by a drop of viscid mucus re- 
sembling in appearance the white of an ^g%. Without 
the aid of the microscope this fluid cannot be distin- 
guished from the mucus secreted by the urethra and 
prostate during sexual excitement ; the redness is no 
more than could come from accidental chafing or fric- 
tion of the parts with the clothing ; and in the majority 
of cases the diagnosis must be withheld for a day or two 
until the beginning of the active or increasing stage. If 
an early diagnosis is important, a drop of mucus should 
be squeezed out of the urethra and be examined for 
gonococci. If they are found, the diagnosis is estab- 
lished at once ; but failure to find them will not warrant 
the exclusion of gonorrhoea until several slides have 
been examined on successive days. 

3. Increasing Stage. — The itching or other sensation 
at the meatus now becomes one of slight burning or 
smarting on urinating, and gradually increases in se- 
verity. The secretion increases in quantity until it is 
sufficient to slightly stain the linen, and becomes thicker 
and opaque. The microscope shows pus-cells which 
increase in number each day. The lips of the meatus 
become more sensitive, red, swollen, and everted, and as 
the disease progresses the entire glans and prepuce may 



376 SYPHILIS AND THE VENEREAL DISEASES. 

gradually share in the inflammatory process. In an 
untreated case these symptoms gradually increase in 
severity for from eight to fifteen days after the beginning 
of this stage. 

The discharge becomes purulent, at first milky, and 
then thicker and creamy in consistence. It grows 
darker in color until of a greenish yellow, the tint being 
due to the presence of a small amount of blood. If the 
mucous membrane becomes cracked, the blood may 
appear in the discharge in streaks, or there may be con- 
siderable hemorrhage. The discharge is often exces- 
sive ; sometimes several drops appear at the meatus, and 
fall, if not wiped away, during the few moments occupied 
by the physician in examining the patient, to whom this 
constant dripping is a source of inconvenience and fre- 
quently of great mental distress. 

The pain on urinating, which at first was slight, 
increases and may become agonizing in severity, caus- 
ing the patient to retain his urine as long as possible. 
Often, when he does urinate he is afraid to permit the 
urine to pass in a full stream, since this would stretch 
the swollen and sensitive mucous membrane and thus 
cause more pain. Then, too, the calibre of the urethra 
is smaller than normal, in consequence of the thicken- 
ing of its mucous membrane, and the stream of urine 
is thus diminished in diameter, divided, twisted, forked, 
and frequently interrupted. The urine may come only 
in drops, or there may be complete retention. This 
last is rare except in the case of an individual who 
had a stricture previous to his present attack. The 
pain, at first located near the meatus, now extends along 
the entire pendulous portion of the urethra, though it 
is usually most intense near the meatus, the fossa na- 



ACUTE URETHRITIS. 2)77 

vicularis, or at the root of the penis. It is not hmited to 
the time of urination, but is more or less constant, and 
it often radiates from the penis to the testicles, cord, 
perineum, groins, thighs, and back. There is also in 
these regions a feeling of weight and tension. 

During this stage there is usually more or less sexual 
irritation, with painful erections and with seminal emis- 
sions which may be mixed with blood. The inflamed 
and thickened mucous membrane of the urethra is not 
capable of distention, and, moreover, the inflammation 
may extend to a part or all of the corpus spongiosum, 
filling up the meshes of its structure with plastic lymph 
and rendering them also incapable of distending to meet 
the demands of the elongated corpora cavernosa during 
erection. These two bodies above, which usually escape 
the inflammation, become distended with blood, elon- 
gated, and pull upon the inflamed and sensitive but now 
inelastic tissues of the urethra and the corpus spongi- 
osum. The result is a torturing pain and a curving of 
the penis forward and downward, forming a bow of 
which the urethra is the taut string. At such a time 
the lips of the meatus may be seen drawn in, forming 
a funnel. This is cliovdce^ and is especially apt to come 
on at night under the influence of the warmth of the 
bed. The sufferer will rise and by the application of 
heat or cold reduce the chordee, only to have it return 
when again he is warmed in bed. In this manner his 
rest at night is broken. Sometimes, becoming desper- 
ate, he attempts forcibly to " break " the cord by resting 
the penis on some hard substance and striking it with 
his fist. The usual result is sudden hemorrhage, and 
later the formation of traumatic stricture. 

The inflammation, at first limited to the lips of the 



378 SYPHILIS AND THE VENEREAL DISEASES. 

meatus, extends until the entire glans is swollen, turgid, 
red, or even highly inflamed and excoriated. The pre- 
puce becomes oedematous, and balanitis of mild or 
severe grade may be present. As a result phimosis 
and paraphimosis are frequent complications. The 
lymphatics of the penis may become inflamed, and 
may be felt as hard cords, usually about the size of a 
knitting-needle, but at times much larger, extending to 
the symphysis pubis. They are usually painful and sen- 
sitive, their course being marked by a red line. Occa- 
sionally these firm cords act upon the erect penis as the 
urethra does in chordee, producing a curvature in vari- 
ous directions. The inflammation of the lymphatics 
usually readily terminates in resolution and does not 
often call for serious consideration. The inguinal glands 
may be involved and become slightly swollen and 
tender, but suppuration is rare. 

Constitutional symptoms are wanting except as they 
result from loss of sleep and from mental distress. The 
latter is often excessive, rendering a man totally unfit 
for his usual vocation. 

4. Stationary Stage. — With good hygienic manage- 
ment the inflammation, after reaching its height, remains 
stationary for about a week, though under unfavorable 
surroundings and in unhealthy individuals this stage 
may be protracted for several weeks. Usually, at the 
end of the third week from the first appearance of the 
discharge the stage of decline begins. 

5. Stage of Decline. — During this stage the symp- 
toms gradually subside; the discharge grows less, until, 
at about the end of the fourth or fifth week, it is again 
represented by only a few drops daily of a sticky 
mucous discharge, which in the course of another week 



ACUTE URETHRITIS. 3/9 

or two disappears entirely, and the patient is well except 
for a sensitive condition of the urethra that will prob- 
ably persist for some weeks. 

The foregoing description applies to an untreated, 
uncomplicated case of gonorrhoea in an otherwise 
healthy man, living under good hygienic conditions, 
who is not subjected to too much physical exertion, who 
is indulging in no excesses in the way of food, drink, or 
tobacco, and who avoids all sexual excitement. In such 
a case the duration of gonorrhoea, from beginning to 
end, is usually from five to eight weeks ; but even in 
uncomplicated and typical cases the disease varies 
greatly in its duration and intensity. The increasing 
stage of the disease, usually about twenty days, may 
be prolonged for weeks ; or after the inflammation has 
reached its height it may remain stationary for some 
weeks instead of a few days. Most frequently pro- 
tracted, however, is the stage of decline. Instead of 
steadily and uniformly progressing to recovery, the 
disease may improve for a time and then remain un- 
changed, or the process may be lighted up afresh and 
recovery be delayed by a series of relapses. 

Frequently, some indiscretion on the part of the patient 
after he considers himself practically well causes a return 
of acute symptoms, though they are rarely so severe in 
type as in the early stages of the disease. Each suc- 
ceeding relapse is usually less severe than that preced- 
ing, but the prolongation of the inflammation increases 
the natural tendency of the disease to localize itself in 
a chronic form in the fossa navicularis, in the region of 
the bulb, or in any part of the urethra that has hap- 
pened to suffer most severely during the acute process. 
Thus are left circumscribed areas of granulation or 



380 SYPHILIS AND THE VENEREAL DISEASES. 

thickening of tissue which may result in chronic gleet 
and may finally go on to the formation of stricture. 

The disease varies as widely in the intensity of its 
symptoms as in its duration. In very mild cases there 
may be, from beginning to end, almost no pain or other 
evidence of inflammation aside from the discharge, which 
may nevertheless be profuse. In the majority of skil- 
fully treated cases of gonorrhoea the other symptoms 
rapidly subside, and the discharge remains the chief, if not 
the sole, source of trouble to the patient. In very severe 
cases, on the contrary, the constant and severe pain, in- 
creased by great sexual irritation, chordee, bloody semi- 
nal emissions, hemorrhages, and discomfort in urination, 
together with mental distress and loss of sleep, tell forci- 
bly on the general health. If the disease extends to the 
posterior urethra — as it does in many cases — one or more 
serious complications (posterior urethritis, epididymitis, 
prostatitis, vesiculitis, or cystitis) may result. 

The causes of this wide variation in the course of 
gonorrhoea lie partly in the peculiarities of the individual, 
but largely in his hygenic surroundings. Syphilis, tuber- 
culosis, scrofula, gout, malnutrition from any cause, and 
great fatigue, all tend to retard the recovery of the dis- 
ease ; while sexual excitement of any kind, the use of 
tobacco, alcohol, or stimulating foods, and too much or 
too vigorous physical exertion, as in walking, dancing, 
or riding, all tend to prolong and increase the severity 
of the inflammation. If a patient with gonorrhoea ac- 
quire a febrile disease, his urethral symptoms usually 
subside while the fever lasts, but return with the disap- 
pearance of the fever. Indigestion, constipation or diar- 
rhoea, and other minor disturbances of the general health, 
as a common cold, usually delay and aggravate the 



ACUTE URETHRITIS. 38 1 

course of gonorrhoea. The first attack, particularly of 
a young man, is, as a rule, the most severe, but it is also 
most likely to terminate in complete recovery. Succes- 
sive attacks may be less severe, but they are generally 
more protracted and obstinate and exhibit greater tend- 
ency to become chronic. 

The symptoms of uoiL-infectioits urethritis may be 
nothing more than a iQ\N drops of muco-pus, possibly 
so small in amount as to cause no more than a slight 
gluing together of the lips of the meatus. Men of 
strumous or lithaemic diathesis, and particularly those 
having a slightly damaged urethra, present these sub- 
acute cases after excesses of any kind. From this low 
type of inflammation there are all gradations to that 
described as the acute stage of gonorrhoea, though 
severe cases are rare, and are usually the immediate re- 
sult of chemical or mechanical violence to the urethra. 
Too frequently they result from local treatment for imag- 
inary ills. The duration of acute symptoms is brief, 
varying from a few hours to a few days. 

Bastard gonorrhce a is usually subacute, presenting the 
symptoms found in the declining stage of gonorrhoea. 
Under simple treatment the urethra thus affected gen- 
erally returns to its former condition in about ten days 
or two weeks. If, under the influence of the irritation, 
the gonococci which may have been lying quiescent in 
the urethra multiply sufficiently, the inflammation may 
be more acute in type, slow in reduction, and in no way 
different from a mild attack of gonorrhoea, except that 
the inflammation reaches its height more rapidly and the 
period of incubation is brief 

Patholog-y. — Our knowledge of the pathology of 
gonorrhoea is very imperfect, owing to the fact that in 



382 SYPHILIS AND THE VENEREAL DISEASES. 

this disease few opportunities are afforded for making 
histological and post-mortem examinations. Finger gives 
the following description of the gross appearances : 
** Urethritis constitutes an inflammation of the mucous 
membrane and submucous tissue, with all its character- 
istics, such as redness and swelling and secretion of a 
mucous, muco-purulent, or purulent discharge. The 
intensity of the inflammation will vary, and hence the 
mucous membrane presents different appearances. Some- 
times the swelling will be slight and the injection den- 
dritic ; sometimes the redness and swelling will be very 
marked. The glands and follicles always appear to be 
affected early and intensely. They become swollen ; 
their openings gape in the shape of a funnel. The in- 
flammation also extends to the lumen of the glands, and 
even the parenchyma takes part in the inflammation and 
in the production of morbid secretion. If the lumen of 
the gland or follicle is now occluded by a firm plug of 
mucus or pus, retention of pus and the formation of 
cysts result. Desquamation of the epithelium and super- 
ficial losses of substance also take place at the mouth of 
the follicle, and if the process is severe may lead to 
small ulcerations (clap-ulcers). Deeper ulcers may also 
develop, perhaps, from the rupture of one or more cysts 
due to occlusion of the gland-openings. This early and 
intense implication of the glands explains the obstinacy 
of clap and its tendency to relapse. The latter is due to 
the persistence of the process, which has died out on the 
surface, in one or more glands, where the virus increases 
and may then be discharged upon the surface ; perhaps 
because the secretion of the virus is increased by local 
and general irritating influences, such as coitus and ex- 
cesses in BacchoT 



ACUTE URETHRITIS. 383 

The histological changes have been studied chiefly in 
gonorrhoeal inflammation of the conjunctiva and the rec- 
tum ; but, reasoning from analogy, it is probable that soon 
after a secretion containing gonococci is deposited upon 
the mucous membrane of the urethra, these micro-organ- 
isms find their way between the superficial cells to the 
deeper epithelial elements and to the upper layers of the 
connective tissue. Here they proliferate, their presence 
causing an irritation which produces an active hyper- 
aemia with dilatation of the vessels and exudation of 
serum. The hyperaemia rapidly becomes an inflamma- 
tion, with the appearance of large numbers of leucocytes 
and round cells in the tissues. The leucocytes make 
their way to the surface, carrying with them large num- 
bers of gonococci. This they continue to do throughout 
the entire course of the disease, until the invading micro- 
organisms are entirely removed. The round-cell infil- 
tration and other evidences of inflammation now disap- 
pear, new epithelial cells take the place of those that have 
been destroyed and exfoliated, and the process is at an end. 

It is not usual for the mucous membrane in all parts 
of the urethra to recover at once. The inflammation 
and the gonococci may linger for months or years in 
one or more glands, in the fossa navicularis, in the cul- 
de-sac of the bulb, or in some other portion that has 
happened to suffer more severely than others. 

Diagnosis. — Exammation of the Patient. — No physi- 
cian will succeed in the treatment of venereal diseases 
who does not habitually make thorough and careful 
examinations. With this end in view he should obtain 
a fairly good knowledge of his patient's general condi- 
tion and history— the more complete the better — before 
coming to the consideration of the local trouble. Other- 



384 SYPHILIS AND THE VENEREAL DISEASES. 

wise this information will be acquired, if at all, in unsat- 
isfactory and detached fragments, and quite probably so 
late as to necessitate changes in instructions and treat- 
ment already given. This not only is a waste of time, 
but it leads to confusion in the mind of the patient and 
does not increase his confidence in his physician. Be- 
sides learning the general state of the health, the physi- 
cian should be informed regarding the habits of eating, 
drinking, tobacco-usage, sleep, exercise, and all hygienic 
surroundings. Exact history of any previous venereal 
diseases should be obtained. 

In the local examination thoroughness is imperative. 
No intelligent practitioner or student of medicine will 
order treatment for a man on the strength of the state- 
ment that he has nothing but a discharge or a " run- 
ning " from the urethra. Nor is it sufficient merely to 
look at the discharge. The clothing should be removed, 
and in the majority of cases the fingers of the examiner 
should first seek the inguinal region. If he finds indu- 
rated, insensitive glands on one or both sides, he will 
search for the initial lesion of syphilis, which he may 
find in the form of a urethral chancre or of a sclerosis so 
trifling that it would pass unnoticed but for the informa- 
tion obtained by the fingers in the groin. If he find a 
single gland enlarged and sensitive, he will suspect the 
presence of chancroid, of a lymphangitis, or of some 
other complication not frequent in gonorrhoea. The 
fingers will next explore the testicles, where the presence 
of indurated nodules in the epididymis may tell of pre- 
vious attacks of gonorrhoea or of syphilis which have 
been denied by the patient and which call for consid- 
eration during the treatment of the present disorder. 

Such an examination of the groins and testicles, if 






ACUTE URETHRITIS. 385 

made at the outset, requires but a few seconds, but if left 
until the fingers are soiled — as they are quite liable to be 
— in the examination of the penis, these regions may be 
neglected. The discharge has led the examiner to make 
a diagnosis of gonorrhoea or urethritis ; the patient com- 
plains of no pain in the groins or in the testicles, and 
their exploration calls for the time and trouble involved 
in an extra washing of the hands. An initial sclerosis, 
acquired at the same time with the gonorrhoea or inde- 
pendently of it, may thus be overlooked, or the patient 
may return in a few days with a violent epididymitis 
which might have been prevented had the evidence of 
former attacks been noted and proper precautions been 
taken. If the prepuce be long or in a state of phimosis, 
the physician will make every effort — cleansing the parts, 
if necessary — to determine that the discharge comes from 
the urethra, and not solely from the preputial sac affected 
with balanitis ; it may come from both. He will also, 
by manipulating the parts, satisfy himself, as far as pos- 
sible, regarding the nature of any other complications 
that may be present. 

Differential Diagnosis. — A urethral inflammation is 
probably one of three conditions — gonorrhoea, bastard 
gonorrhoea, or simple urethritis. The first is the most 
common, constituting a large majority of all cases ; the 
second is of frequent occurrence ; while non-infectious 
urethritis pure and simple, occurring in a man whose 
urethra was previously sound, is unusual. It is evident 
that the diagnosis between bastard gonorrhoea and 
simple urethritis will often be made with great difficulty. 
If repeated examinations fail to find gonococci in the 
discharge, the diagnosis must rest upon the history of 
the patient. If he has had former urethral discharges, 

25 



386 SYPHILIS AND THE VENEREAL DISEASES. 

it is safe to assume that his urethra had never fully- 
recovered from the earlier attacks. In these cases an 
accurate diagnosis, so far as the immediate treatment is 
concerned, is not essential, for in either case the dis- 
charge usually subsides in a few days under simple 
treatment ; the diagnosis, however, is of importance in 
the matter of prognosis and in determining the proper 
course to be pursued in the future. 

The average patient can with difficulty wait for the 
conclusion of the examination before asking to be 
informed definitely if he has true gonorrhoea or if his 
discharge results from what is popularly known as " a 
strain " or from contact with innocent vaginal discharges. 
In almost the same breath he will probably ask how 
long a time is required for " curing " him. These ques- 
tions can often be answered at once, but frequently they 
call for the exercise of much tact, good judgment, and 
good sense on the part of the physician. The man who 
indulges in illegitimate sexual relations with a mistress 
or with a woman generally supposed to be respectable is 
loath to believe that he is infected. He is often positive 
in his declarations that he has not been exposed to 
a venereal disease. Egotism and ignorance give him 
faith in a woman he personally knows to be immoral. 
The man, further, who indulges in promiscuous sexual 
relations, relying for his safety upon artificial methods 
and devices for avoiding disease, is slow- to realize that 
his precautions have failed to protect him. Such 
measures are certain to fail sooner or later. 

On the contrary, the young practitioner is inclined to 
be too incredulous regarding urethral discharges de- 
clared to have been innocently acquired, and rarely 
properly appreciates the fact that a large proportion 



ACUTE URETHRITIS. 



387 



(possibly one-third) of the seemingly acute and subacute 
cases are in reality exacerbations, wrought by some of 
the causes already discussed, of a pre-existing chronic 
disease. While in the majority of cases the diagnosis 
may be made with precision on the first examination, 
especially if the microscope be used, there are times 
when the prudent physician will postpone his decision 
for a few days, and will consider carefully the individual- 
ity and surroundings of his patient before answering the 
questions put to him. His aim must be to relieve the 
suffering and to protect the innocent. 

The diagnosis practically lies between gonorrhoea, bas- 
tard gonorrhoea, and a simple urethritis. Their causes, 
characteristics, and symptoms need but brief review here. 
For convenience they are set forth in tabular form. 



Gonorrhcea. 

History of former attacks 
not necessary. 

The patient's general con- 
dition has no bearing on 
the origin of the disease, 
but may exert a marked 
influence on its course. 

Urethra may have been 
soimd at the time of in- 
fection. 



Cause of disease lies solely 
in exposure to a gonor- 
rhoeal discharge. 



Bastard Gonorrhoea. 

The patient has had former 
attacks. 

Enfeebled constitution is 
often a factor in the pro- 
duction of the disease, 
and frequently exerts a 
decided influence on its 
course. 

Damaged condition of ure- 
thra necessary. Gener- 
ally evidenced by gluing 
of lips of meatus in the 
morning, or by shreds in 
the urine. Patient may 
have seen no evidence of 
disease for months, and 
believed himself well. 

Immediate cause usually 
found in sexual indul- 
gence, with or without 
other excesses. Occa- 
sionally other excesses 
are alone sufficient. 



Non-infectious Ureihritis . 

History of former attacks 
not necessary. 

Enfeebled constitution is 
sometimes the chief fac- 
tor in the production of 
the disease, and may even 
be the sole cause of its 
continuance. 

Damaged condition of ure- 
thra not necessary, but 
probably present in many 



Cause found in direct me- 
chanical or chemical vio- 
lence to the urethra, often 
the result of too ener- 
getic treatment. In the 
cachectic and debilitated, 
sexual and other excesses 
may suffice. 



388 SYPHILIS AND THE VENEREAL DISEASES. 



GonorrJma. 

Period of incubation 
ranges from one to four- 
teen days, rarely less 
than three, and usually 
from five to seven. 

Begins with slight symp- 
toms, which gradually 
increase in severity for 
from ten to fourteen 
days, when the inflam- 
mation is usually of a 
very high grade. 

Duration is usually from 
five to eight weeks. 
Acute stage lasts three 
or four weeks. 

Discharge contains gono- 
cocci in large number. 



Bastard Gonorrhoea. N'on-infectioiis Urethritis. 

Period of incubation usu- No period of incubation, 
ally one or two days. Symptoms usually appear 

in a few hours. 



Usually subacute through- 
out. When more acute, 
the symptoms increase in 
severity more rapidly, 
but rarely become so se- 
vere as in gonorrhoea. 

Duration very indefinite — 
perhaps one or many 
weeks. Acute stage usu- 
ally lasts a week or ten 
days. 

Gonococci usually present 
in small number. 



Inflammation reaches its 
height in a few hours. 
If resulting from marked 
violence to the urethra, 
symptoms may be very 
severe; otherwise it is 
usually subacute in type. 

Acute forms usually recover 
in a few days, as do the 
subacute cases, though 
the latter may continue 
in chronic form. 

No gonococci. 



The microscopic examination should be conducted 
with great care, all instruments, preparations, slides, and 
cover-glasses being scrupulously clean. If the first 
slide examined shows typical gonococci in abundance, 
and all the other evidence points to a gonorrhoea, there 
can be no doubt of the diagnosis ; but if the first slide 
fails to show gonococci, at least two or three others must 
be properly prepared and examined before excluding 
gonorrhoea. In very early stages, while the discharge 
is yet muco-purulent, the number of gonococci present 
is much smaller, and several slides should be examined 
on successive days before deciding that gonorrhoea is 
not present. In the declining stage it is even more dif- 
ficult to find gonococci, as they are present in smaller 
number and are not infrequently associated with other 
micro-organisms which lead to error in diagnosis. Even 
during the purulent stage the gonococci are not evenly 
distributed through the discharge, but are usually most 
abundant in those drops which come from a portion of 



ACUTE URETHRITIS. 389 

the surface most recently inflamed; consequently it is 
always best, for purposes of examination, to squeeze 
out a drop from the deeper portions of the urethra, 
instead of taking that which happens to be at the 
meatus. In a true gonorrhoea, however, the gonococci 
are usually present in sufficient number to render their 
demonstration comparatively easy, and the discovery 
of only a few diplococci in an acute urethritis does not 
warrant a diagnosis of gonorrhoea. The dried gonor- 
rhoea! discharge found on clothes or the underwear of 
a patient, if moistened, removed, and properly stained, 
may show gonococci. 

Besides the gonococci and the pus-cells containing 
them, the microscope shows, in the earlier discharge, 
many flat epithelial cells. These cells gradually dis- 
appear, and the field is completely filled with pus-cells, 
which in turn become less numerous as the discharge 
decreases, and, instead of the flat epithelium of the early 
stage, cells of transition epithelium are seen, often in 
considerable numbers. 

In the examination of any urethral discharge the 
possible presence of posterior urethritis should always 
be kept in mind. If the urine be given a careful exam- 
ination and the two-glass method be employed, the 
diagnosis will not be difficult. 

Treatment. — Prophylaxis. — American and English 
writers have been criticized for neglecting to discuss 
prophylaxis in their works on gonorrhoea. At first 
thought such a discussion would seem superfluous, but 
there undoubtedly exists among the laity, and, unfor- 
tunately, among some physicians, the belief that there 
are means by which a man may protect himself from 
venereal diseases while indulging in promiscuous sexual 



390 SYPHILIS AND THE VENEREAL DISEASES. 

relations. Of the various devices and methods recom- 
mended and employed, there are none that can be 
trusted to ensure the desired end. The large majority 
of men who resort to these means in illicit sexual rela- 
tions sooner or later become infected with disease. The 
only prophylaxis a right-minded physician can advise is 
clean living. 

General Considerations. — In the entire range of medi- 
cine there are few diseases in which so many remedies 
have been tried, and in which so many methods of treat- 
ment have been advocated, as in gonorrhoea. An at- 
tempt to describe them all would be useless. In these 
pages space is given only to such methods of treatment 
as experience has proved to be of value in mitigating 
the violence or in shortening the duration of the disease. 
These methods, unless otherwise indicated, relate to the 
treatment of true gonorrhoea. The discovery of gono- 
cocci in a discharge makes it possible to predict, within 
certain bounds, the intensity and duration of the dis- 
order, demonstrates its contagious nature, and calls for 
much care and caution not necessary in the management 
of a non-infectious urethritis. From a therapeutic point 
of view, however, no important distinction is made be- 
tween the different forms, an inflammation of a given 
intensity calling for a given treatment. The duration 
of any one stage in the non-infectious forms is, of course, 
brief as compared with a corresponding stage of gonor- 
rhoea, and much treatment other than hygienic is rarely 
called for. Usually, removal of the cause, rest, and 
perhaps an alkali to ensure a bland condition of the 
urine, are all that are necessary. In bastard gonorrhoea 
the symptoms are usually subacute, though they may 
be severe. The treatment is that recommended for cor- 



ACUTE URETHRITIS. 39 1 

responding stages and degrees of inflammation in gon- 
orrhoea. 

Abortive Treatment. — Many abortive measures for the 
treatment of gonorrhoea have been recommended by 
reputable physicians, and " rapid cures " are regularly 
advertised in the public press. But these novel methods 
that promise quick results are not unattended by danger. 
The practitioner who is strongly tempted to try the last 
highly recommended local treatment in the hope of 
benefiting his patient should recognize these dangers 
and should remember that there is a great difference 
between checking a discharge and curing the disease. 

Since the recognition by Neisser of the gonococcus as 
the essential cause of gonorrhoea, numerous efforts have 
been made to discover some means of destroying the 
micro-organism and of thus preventing the further exten- 
sion and continuation of the disease. Many agents are 
capable of at once destroying the gonococci when brought 
in contact with them, but they also either prove so de- 
structive to tissue or so aggravate the existing inflamma- 
tion that the resulting damage to the urethra is greater 
than that produced by the gonococcus. Injections of 
strong solutions of nitrate of silver or of bichloride of 
mercury or of other preparations have in some instances 
destroyed the micro-organism, and aft^r causing an intense 
inflammation of the mucous membrane have seemed to 
shorten the duration of the disease. More frequently 
such treatment has failed to destroy all the gonococci, 
and has resulted in complications which prolong the dis- 
ease and add to its severity. 

The investigations of Bumm and others have shown 
that the gonococci rapidly find their way beneath the 
epithelium to the papillary body and to the lymph-spaces 



392 SYPHILIS AND THE VENEREAL DISEASES. 

of the upper connective-tissue layers. Here they multi- 
ply and are brought to the surface by the leucocytes. 
It is not strange, then, that abortive measures fail, since 
parasiticides cannot be brought in contact with the more 
deeply seated gonococci without first destroying the epi- 
thelium. A local application that will meet the three 
requirements of Neisser — that is, a remedy that will kill 
the gonococcus, leave the mucous membrane uninjured, 
and not increase the inflammation — is yet to be dis- 
covered. As a consequence, up to the present time 
all attempts at abortive treatment have been failures. 
The cases reported to have been aborted by local treat- 
ment were possibly of the class of non-infectious ure- 
thritis or bastard gonorrhoea, that would in any event 
have run a brief course. Others were perhaps cases of 
true gonorrhoea, dismissed and reported as cured as soon 
as the discharge ceased. It is now known that the ure- 
thra may not return to its normal condition for weeks 
after the discharge disappears, and that often such cessa- 
tion of the discharge proves to be only temporary. 

Local Treatment in tlie Early Stages of Go nor rl ice a. — Re- 
garding the propriety of using local treatment in the acute 
stage of gonorrhoea authorities widely differ. The treat- 
ment of gonorrhoea will at some future date, perhaps, be 
purely local, but there has not yet been found a method 
of local treatment in the acute stages of gonorrhoea that 
is completely efficacious, or even wholly safe, in the hands 
of any but the expert. 

The method by irrigation, which once promised so 
much and which had so many enthusiastic advocates, is 
rapidly becoming a thing of the past. When properly 
pursued, and with mild solutions, it served admirably in 
cleansing the urethra, in subduing to some extent the in- 



ACUTE URETHRITIS. 393 

flammation, and in modifying the symptoms. The dis- 
charge frequently ceased after two weeks of treatment ; 
but that irrigation restores the urethra to a healthy con- 
dition sooner than other forms of treatment has not been 
proved. It is a difficult method to pursue, except where 
the patient is under complete control, as in a hospital, and 
in any but the most skilful hands it often results in com- 
plications (epididymitis, prostatitis, posterior urethritis, 
etc.) necessitating the cessation of treatment. Recently, 
Finger found that pure cultures of the gonococcus could 
be exposed for two minutes to the action of bichloride of 
mercury (i : 5000), carbolic acid (i : 1000), potassium per- 
manganate (i : 1000), or nitrate of silver (i : looo), and 
yet grow when transferred to plate-cultures. This being 
true, it is apparent that irrigation as usually employed 
would not destroy the gonococci in the urethra, but would 
simply remove such as were on the surface. 

Powders and soluble suppositories are not to be con- 
sidered. They almost invariably do harm. Mild astrin- 
gent and cleansing injections are, however, still largely 
used, even in the early stages of gonorrhoea. They 
very rapidly lessen the amount of discharge ; clinical 
experience, however, shows that they fail to shorten the 
duration of the disease, but rather tend to prolong it in a 
subacute stage. Certain it is that disagreeable and serious 
complications occur much more frequently in cases treated 
by injections from the start than in cases in which no in- 
jection is used until the most active stage of inflamma- 
tion has passed. The substances injected are either 
antiparasitic or astringent, or both. The parasiticide may 
destroy some of the gonococci, but it cannot reach many 
of them during the early stages ; the astringent may, and 
probably does, lessen the intensity of the inflammation, 



394 SYPHILIS AND THE VENEREAL DISEASES. 

but it is questionable if it is best to push this effect too 
far, as inflammation and suppuration are nature's methods 
of removing the offending micro-organism, which as yet 
cannot be destroyed by any more rapid process. One 
cannot hope to eradicate the disease before its cause has 
been removed. If Metschnikoff's theory of inflammation 
be accepted, and the leucocytes be viewed as phagocytes, 
it certainly is not desirable by constringing the vessels to 
limit the number of such leucocytes, whose duty it is to 
devour and remove the gonococci. Metschnikoff"'s theory 
is both interesting and plausible ; applied to urethral in- 
flammation, it is sustained by abundant clinical evidence 
showing that when the inflammation and discharge are 
suppressed by the use of injections in the early stages of 
gonorrhoea, the disease runs a mild but protracted course, 
and the last lingering discharge shows gonococci for a 
longer period than in cases which have had the usual two 
or three weeks of acute inflammation followed by a period 
of steady but more rapid decline. 

The danger in this direction, however, is possibly not 
so great or so frequent as that resulting from the use of 
irritating injections which increase the inflammation to 
such an extent that posterior urethritis, epididymitis, 
prostatitis, cystitis, or vesiculitis results. These compli- 
cations are often very painful, necessitating the suspen- 
sion of all treatment for the gonorrhoea, and frequently 
compelling the patient to remain in bed for days or weeks. 
Unless the physician has had large experience in this 
class of cases, and has his patient under his immediate 
control, local treatment of gonorrhoea should not be 
begun until the active has passed into the subacute stage ; 
and many patients will make a complete and satisfactory 
recovery without receiving at any time local treatment. 



ACUTE URETHRITIS. 395 

Hygienic Management. — There is practical unanimity 
of opinion on at least one point in the treatment of 
gonorrhoea — namely, that proper hygienic surroundings 
are of great importance. There is no better treatment 
for the large majority of all first attacks of gonorrhoea 
than rest in bed for three or four weeks, with absolute 
quiet, freedom from sexual excitement, a light and 
simple diet, a daily movement of the bowels, and a 
proper performance of the other bodily functions. Un- 
fortunately, it is rare that such a course can be pursued. 
Few men with a gonorrhoea are willing, unless com- 
pelled to do so, to abandon their usual vocation, and 
many, through fear of disclosing their condition, will 
continue their work notwithstanding most painful com- 
plications and contrary to their physician's orders. 
Through fear of betraying his' secret to his companions 
or to members of his household a man will often fail to 
obey the instructions given him, and refuse to change 
his habits to meet the requirements of his case. 

One of the first points, therefore, to be secured in the 
management of a case of gonorrhoea is a complete under- 
standing on the part of a patient that it is necessary for 
him to carry out faithfully the instructions given, and 
that he is thus responsible, to a great extent, for the 
result. This is not usually an easy matter, as the idea 
is often firmly fixed in the mind of the patient that an 
injection will accomplish all that is necessary, with little 
or no effort on his part. The practitioner who takes the 
time and pains to point out the truth will have far better 
results, and meet with much less annoyance, than if he 
devote his time to making trial of the last highly recom- 
mended and best-advertised injections. The manage- 
ment of gonorrhoea cannot be made a matter of routine, 



396 SYPHILIS AND THE VENEREAL DLSEASES. 

but requires always some consideration of the individual 
and his surroundings. Directions should be given 
clearly and in detail. 

(a) Rest. — The patient should spend all the time pos- 
sible in the recumbent position. This is of special ser- 
vice during the early acute stages, since, by removing 
the pressure of blood from above, it lessens the conges- 
tion of the parts. All violent exercise, such as gymnas- 
tics, running, dancing, and horseback- or bicycle-riding, 
should not be practised, and even walking or much 
standing is harmful. 

(b) Food. — The more nearly the patient can restrict 
himself to bread and water or bread and milk, the 
better; but if he must continue his usual work or a 
portion of it, or if he be already poorly nourished, a 
more nutritious diet is necessary. Such he may find 
in fish, the lighter meats, soft-boiled eggs, and cooked 
vegetables. As a rule, he should avoid all articles 
difficult of digestion, all rich or highly seasoned food, 
and all acids, sweets, and especially fats. 

{c) Beverages. — Alcohol in all forms, and especially 
in the form of malt liquors, is prohibited. Coffee, 
chocolate, and cocoa are injurious, but tea in modera- 
tion may be allowed. Milk is of value, and may be 
given freely if it agrees with the individual. Pure water 
does excellent service if drunk in quantities sufficient to 
keep the urine bland and unirritating. Smaller amounts 
of Vichy, seltzer, or other alkaline waters answer the 
same purpose. If there be much burning on urinating, 
and frequent desire to pass urine, a thin, strained, flax- 
seed-tea (made from the whole seed and rendered palata- 
ble by the addition of a small quantity of lemon-peel) 
will often give relief if drunk in quantities of a quart or 



ACUTE URETHRITIS. 39/ 

more daily. Lemonade is usually agreeable to the 
patient, and, like some other vegetable acids, is occa- 
sionally of service in rendering the urine alkaline, the 
more so if a small quantity of bicarbonate of soda be 
added ; but it does not ansv/er equally well in all cases, 
and sometimes proves decidedly irritating. 

id) Tobacco in all forms should be avoided. Smok- 
ing is especially bad. 

{e) All sexual relations and stimulation of the sexual 
organs are harmful, and the patient should avoid com- 
pany, books, pictures, thoughts, and circumstances that 
might result in sexual excitement. He must determine 
to do this at once, since the congestion and inflamma- 
tion of the parts, due to his gonorr,hoea, are alone suf- 
ficient to keep them in a state of irritation. For the 
purpose of lessening the tendency to congestion of the 
genitals, there should be a daily evacuation of the bowels 
by the aid of saline laxatives. The patient should sleep 
in a cool room, on a hard mattress, and without too 
much covering ; the married man should not occupy the 
same bed with his wife. The immersion of the genitals 
in water as hot as can be tolerated, and for a few seconds 
only, just before retiring, often reduces the frequency of 
annoying and painful erections. A longer use of cold 
water may answer the same purpose, and both means 
are valuable in reducing erections w,hich awaken the 
patient during the night. On the contrary, prolonged 
hot or warm baths are harmful in that they encourage 
the local congestion. Urinating while the penis is im- 
mersed in hot water usually renders that act less pain- 
ful. 

(/) Dressing of the Parts. — Cleanliness is of first im- 
portance ; the parts should be washed daily in warm 



398 SYPHILIS AND THE VENEREAL DLS EASES. 

water, using soap on all but the inflamed surfaces, and, 
of course, keeping it out of the urethra. The patient 
should wash his hands after each dressing, and should 
be instructed regarding the great danger attending the 
contact of the smallest amount of the discharge with the 
eyes. To catch the discharge and to protect the patient's 
clothing, the penis may be carried in a light muslin bag 
containing in the bottom a small quantity of cotton, the 
bag being fastened by means of tape to a suspensory 
bandage or to a band about the waist. A simple and very 
satisfactory method is to take two thicknesses of ordinary 
muslin, about a foot square, and so pin them to the inner 
surface of the undershirt that the penis can be gathered 
up in their folds. These cloths are cheap, and can easily 
and quickly be removed, burned, and replaced by fresh 
pieces — if necessary, several times during the day. If 
desired, a pair of swimming-drawers can be worn beneath 
the other underwear, and will serve to hold the muslin 
in better position. Keyes recommends wrapping the 
penis in two sheets of ordinary toilet paper and twisting 
the free end, forming a paper bag in which to catch the 
discharge. 

Rubber and oiled-silk bags, and all heavy wrappings 
of the penis, are decidedly harmful, in that they tend 
to keep the organ hot and congested. Dressings 
should never be tied to or about the penis, since they 
interfere with the circulation and usually cause a trou- 
blesome oedema of the prepuce. Nor, for catching the 
discharge, are pieces of cotton or other dressings held 
in place by a long prepuce to be recommended, since 
they imprison the pus within the urethra, and also keep 
it in contact with the sensitive mucous membrane of the 
glans and prepuce, thus often exciting a balanitis. 



ACUTE URETHRITIS. 399 

If the patient is required to be active or on his feet 
much of the time, and particularly if with a former 
gonorrhoea he has had an epididymitis, he should wear 
a well-fitting suspensory bandage. The first object of a 
suspensory is to support and elevate the scrotum and 
the testicles, relieving the tension on the cord, at the 
same time slightly lessening the blood-pressure and aid- 
ing the return circulation. This object can be accom- 
plished by a single bag of proper depth and width to fit 
the parts, suspended only from a waistband. The bag 
must not be too deep, or it will not furnish support; 
while if too shallow it will exert uneven pressure and 
will slip off, not retaining the parts. Frequently a bag 
that does not fit well can be made to do so by lining and 
filling out some parts of it with antiseptic wool. Cotton 
is not so good, as it soon mats and becomes hard. 

This simple suspension of the genitals may be sufficient 
in many cases, but if there be the slighest tendency to in- 
volvement of the cord or the testicles, another object is 
to be accomplished — the subjection of the testicles to 
as little motion as possible in walking or during other 
movements. For this purpose the suspensory bandage 
described above will need, in addition, some perineal or 
thigh-straps that will hold the organs snugly against the 
symphysis. In order to do good, and not harm, a sus- 
pensory must fit snugly, but must not be too tight, nor 
should it press upon any portion of the urethra. It is 
usually most serviceable when it is most comfortable to 
the patient. Instead of a suspensory bandage a jock- 
strap may be used, though it is not so convenient and is 
usually more difficult to fit properly. Tight- fitting 
swimming-drawers of firm material often answer every 
purpose. An excellent substitute for any of the pre- 



400 SYPHILIS AND THE VENEREAL DISEASES. 

ceding may easily be made as follows : Pass a bandage, 
of such material and width as will be comfortable, around 
the waist for a belt ; take a strip of soft linen or several 
thicknesses of cheese-cloth or mull, about eight inches 
wide, and fasten one end of this to the middle of the belt 
behind with safety-pins ; bring it between the buttocks, 
over the perineum, and up to the belt in front, where, by 
fastening at several points, it can be made to fit the genitals, 
elevating them and holding them close against the body. 

Internal Treatment. — In the early stages hygienic 
management is of first importance. Fournier and other 
French authorities advocate no other treatment internally 
or locally until the stage of decline. This is the so- 
called " expectant plan." While the use of large doses 
of the balsams with a view to aborting the disease is 
not to be recommended, its early stages may be rendered 
much less severe, and the entire course of gonorrhoea 
be shortened, by the proper use of internal remedies. 

Alkalies and diuretics are of decided value in keeping 
the urine bland and unirritating, and should be used in 
sufficient doses throughout the disease to accomplish 
that end, unless the fluids daily ingested prove sufficient 
for the purpose. Excellent results are obtained from 
the use of bicarbonate of soda or of citrate of potash in 
doses of from 5 to 20 grains three or four times daily ; 
the latter acts also as a diuretic, and is in some cases to 
be preferred. The quantity required will vary from day 
to day, enough being given to keep the urine alkaline. 
If taken about two hours after eating, the effect upon 
the urine is more pronounced than if given at any other 
time, and interference with digestion is not so marked 
as when taken immediately after eating. Consequently 
it is often well to prescribe these remedies in the form 



ACUTE URETHRITIS. 4OI 

of compressed tablets of 5 grains each, that can easily 
be carried in the pocket and swallowed at any time with 
a glass of water. They may also be given in simple solu- 
tion, in peppermint-water, or with any flavoring desired. 

Balsam of copaiba^ if easily digested by the patient, 
is one of the most valuable of drugs, but there are 
unquestionably certain individuals who cannot digest it. 
It should never be ordered if it disturbs digestion and 
nauseates so that the patient cannot eat, though many 
who at first had some difficulty in its digestion soon 
manage very well if it be taken in small but gradually 
increasing doses an hour or two after eating (occasion- 
ally some other hour will be found to be better), or if 
some preparation of pepsin be taken with it. Occasion- 
ally a few doses of the drug cause the appearance of an 
exanthem known as the copaiba rash. This is a bright 
red eruption of macules or maculo-papules over the 
abdomen and the extremities, or even over the entire 
skin-surface. The eruption appears rapidly and is ac- 
companied by pruritus. It is a trifling complication, dis- 
appearing promptly on withdrawal of the copaiba, but it 
is a source of annoyance to the patient and necessitates 
the abandonment of the drug. 

If copaiba is digested reasonably well, it is usually 
of great service and may be given from the beginning, 
though if digested with some difficulty its use should 
be postponed until the stationary stage, at which time 
it is of pronounced value. Many object to the use of 
the balsamic preparations in the early stages of gonor- 
rhoea, on the ground that they are stimulating to the 
mucous membrane. Clinical experience, however, 
teaches that copaiba very markedly lessens not only the 
discharge, but also the painful and distressing symptoms 

26 



402 SYPHILIS AND THE VENEREAL DISEASES. 

of the acute stages, and, moreover, shortens the duration 
of the disease. Finger states that he beheves copaiba 
taken internally acts in the urine as a parasiticide, 
destroying some of the gonococci. The action of 
copaiba (and allied drugs, such as sandalwood and 
cubebs) is undoubtedly local, and is due either to the 
drug itself or to the products of its metamorphosis 
present in the urine as it passes over the mucous mem- 
brane of the urethra. This fact was demonstrated by 
Ricord and Roquette in patients with urethral fistulae 
who acquired gonorrhoea. While taking copaiba inter- 
nally the portion of the urethra, back of the fistula, that 
was washed by the urine showed marked improvement, 
while no change was apparent in the part anterior to the 
fistula, and through which no urine passed. The patient 
continuing the internal use of the balsam, some of his 
urine was injected into this anterior portion of his 
urethra, the result being a lessening of the inflammation. 
In examining the urine of a patient who is taking 
copaiba it must be remembered that the mineral acids 
produce with it a flocculent precipitate which can easily 
be mistaken for albumin. This precipitate is soluble in 
an excess of acid or in alcohol. Copaiba is best given 
in the form of the balsam, either in capsules of lo minims 
each or in one of the following preparations : 



^. Balsam, copaibse, 
Syr. tolutani, 
Acacise pulvis, 
Sacchar. albi, aa. q. 


iss-ij ; 
s. ad ft. emuls. 


Lavand. spirit.. 
Aquae destilL, 
Ft. emulsio. 


3j; 

q.s. ad ^vj. — M. 


Sig. Teaspoonful dose. 





ACUTE URETHRITIS. 403 

^. Potassae citratis, 3ij-vj ; 

Balsam, copaibae, 3iij-vj ; 

Extr. fl. hyoscyami, 3ss-3ij ; 

Syr. acaciae, 5iss ; 

Aquae nienth. pip., q. s. ad ^iij. — M. 
Sig. Shake. Teaspoonful in water. 

The last preparation is recommended by Keyes, who 
adds that " The mixture may be largely modified by sub- 
stituting sandalwood oil for copaiba, leaving out the 
hyoscyamus w^hen not required, substituting bicarbonate 
of soda for the citrate of potash if the diuretic effect is 
not desired, and wintergreen-water for mint-water, or 
even adding licorice, according to taste." Oil of sandal- 
wood or oil of cubebs may be added to either of the 
above emulsions if desired. 

The remarks made with reference to copaiba apply in 
the main to the oil of sandalwood. The latter is, how- 
ever, more easily digested and does not produce an 
exanthem, though it may cause congestion of the kidneys 
with resulting characteristic pains in the back and the 
loins. In a majority of cases, owing to the uncertainty 
of obtaining the pure drug, less uniform results are ob- 
tained from the oil of sandalwood than from copaiba ; 
but while it is not so efficacious in subduing the painful 
symptoms of the acute stages, it often seems more effec- 
tive in reducing a subacute discharge. It should be 
tried in the acute stages instead of copaiba when the 
latter is not tolerated. It is best given in capsules each 
of 10 minims ; or it may be dropped on lump-sugar, in 
which case an ounce of sandalwood oil may be flavored 
by adding to it 10 or 15 drops of the oil of wintergreen 
or the oil of peppermint ; or it may be substituted for 



404 SYPHILIS AND THE VENEREAL DISEASES. 

copaiba in either of the emulsions for which formulas 
have been given. 

Preparations of aibebs are, as a rule, too stimulating to 
be given while the inflammatory symptoms are at all 
marked. They are of great service in checking the last 
drops of a lingering discharge, either at the close of an 
acute case or in subacute and chronic cases. They 
usually cause no disturbance in digestion, and they fre- 
quently act as tonics to the stomach. The best prepa- 
ration, if fresh, is the powder. It should be given in 
doses of from lO grains to 2 drachms. When desired 
by the patient, it may be given in capsules or be admin- 
istered in some syrupy or mucilaginous drink. The 
oleoresin in lo-minim capsules, from one to three at a 
dose, is perhaps as good as the powder; while the fluid 
extract in from lo-minim to drachm doses often gives 
good results. In stubborn cases of subacute and torpid 
type it is advisable to make occasional changes in the 
preparations given. Good results are often obtained 
from a combination of cubebs and sandalwood, with the 
addition sometimes of copaiba. 

In prescribing any one or all of these preparations sev- 
eral rules should be observed. A dose on retiring for 
the night should be given, in addition to that after each 
meal, thus keeping the urine constantly under the influ- 
ence of the drug. The doses should be small at first, 
particularly in the early stages, and should gradually be 
increased up to the full tolerance of the patient's stomach, 
or until the desired effect is produced ; for if this can be 
accomplished in smaller, it will, of course, be worse than 
useless to give larger doses. If, after a week or two of 
full doses, no benefit has been derived from the drug 
(provided always that the patient has had proper hygienic 



ACUTE URETHRITIS. 405 

management and surroundings), or if the patient's stomach 
begin to rebel, a change to one of the other preparations 
should be made. No one of these remedies, particularly 
copaiba, should be given continually through too long 
a period. If, at the end of one, two, three, or four weeks, 
symptoms of gastric disturbance begin to appear, or if, 
in the case of sandalwood, there are indications of con- 
gestion of the kidneys, such as pain, or a sense of burn- 
ing and oppression in the loins, another drug should at 
once be substituted. 

Treatment of Successive Stages of Gonorj-Jioea. — Atten- 
tion to all the details of hvg-ienic manag'ement are of the 
greatest importance in all the stages of gonorrhoea, and 
have been fully discussed in the preceding pages. 

(a) Prodromal Stage. — It is not often that the physi- 
cian has a chance to observe this stage of the disease, 
which usually lasts but a day or two, and passes un- 
noticed by the average man unless he is watching him- 
self in fear of the possible result of a suspicious inter- 
course. If there is a clear history of exposure followed 
by a period of incubation, and certainly if there can be 
expressed a drop of mucus in which there are a few 
gonococci, gonorrhoea will undoubtedly follow, and the 
patient should be put under hygienic treatment at once, 
with the addition of an alkali internally. If circumstances 
point rather to the presence of a non-infectious urethritis, 
the same treatment will do no harm, though it may not 
be necessary to interfere to the same extent with the 
patient's habits of living, removal of the cause if discov- 
ered, the administration of an alkali, and rest being in 
the majority of cases all the treatment that is necessary. 
The general condition of the patient may call for con- 
sideration. 



406 SYPHILIS AND THE VENEREAL DISEASES. 

[b) Increasing Stage. — During this stage the patient 
with a well-managed case of gonorrhcea usually finds 
his chief source of anxiety in the urethral discharge, and 
looks upon its daily increasing amount with much ap- 
prehension. It is then that the physician is tempted to 
satisfy his patient by using methods that will promptly 
check the discharge, and in this course there may be 
danger. Often, by too vigorous local treatment the 
modification of the discharge is followed by complica- 
tions so painful and distressing that the sufferer would 
gladly welcome a return to the discharge if he could be 
relieved from his new and serious symptoms. The 
treatment in this stage should therefore be directed more 
to the alleviation and, if possible, prevention of painful 
symptoms and complications, and to the general condition 
of the individual, than to the suppression of the discharge. 

The pain and burning on urinating — a7'dor tirincE — 
should be controlled, if possible, by drinking large quan- 
tities of fluid to dilute the urine, and, as already described, 
by the use of alkalies. This object will nearly or 
wholly be accomplished when the urine is kept alkaline. 
Some preparation of copaiba or of sandalwood may then 
be given in small doses. In cases where the pain is 
very great, much relief is afforded by immersing the 
penis in hot water during the act of urinating. If these 
means are found in any case to be impracticable, the 
fluid extract of hyoscyamus may be given with the alkali 
several times a day, in doses of from i to 5 minims. The 
injection of a weak solution of cocaine just before urinat- 
ing is recommended by some authors, but its use does 
not to any great extent lessen the amount of pain, and 
it must be remembered that deaths have been reported 
from the use of cocaine in the urethra. 



ACUTE URETHRITIS. \0*J 

In cases of complete i^etcntion or where the urine will 
pass in drops only, a good plan is to place the patient in 
a hot-water bath — a sitz-bath will answer — and allow 
him to stay there quietly for a few minutes, an hour if 
necessary, until the urine passes. This is a most effec- 
tual means of emptying the bladder without distress to 
the patient, and it usually enables him to urinate with 
much less difficulty the next time the act is attempted. 
Occasionally this procedure will not suffice, and a cathe- 
ter must be used ; this should be soft and small, in size 
about No. 12 or 14 of the French scale, and should be 
introduced with great care, after first injecting the urethra 
with warm olive oil, that its inflamed membrane may be 
damaged as little as possible. The operation is made 
still easier if, in addition to the above precautions, the 
catheter is passed while the patient reclines in the bath. 
A careless use of the catheter will damage the mucous 
membrane, add to its swollen condition, and therefore 
increase the urethral obstruction. If other means fail, 
ice in the rectum may be tried. It should be pulverized 
and put in a suitably shaped flannel bag. Finally, aspi- 
ration may be necessary. Complete retention is, how- 
ever, unusual, unless the patient before acquiring his 
gonorrhoea had a stricture. 

The treatment of chordee and other forms of sexual 
irritation attending gonorrhoea must be chiefly hygienic, 
and has already been considered, the requirements being 
absence of all sexual excitement, a light diet, regular 
daily evacuation of the bowels, sleeping in a cool room 
on a hard mattress without too much covering, and the 
immersion of the penis for a few seconds in hot water or 
for a longer period in cold water, just before retiring, to 
be repeated during the night if necessary to reduce pain- 



408 SYPHILIS AND THE VENEREAL DLSEASES. 

ful erections. If the patient is in the habit of sleeping 
on his back, he may lessen the congestion of the genitals 
by lying on his side. He can force himself to do this 
by tying a towel about his waist with the knot resting 
on his- spine. If all these details are faithfully carried 
out, it is rare that camphor, belladonna, lupulin, bromide 
of potassium, and other so-called " anaphrodisiacs " will 
be needed, or, if tried, will be found beneficial. They 
are all unsatisfactory, and frequently disturb the func- 
tions of other organs of the body. Lupulin is probably 
the best of the list, and bromide of potassium the next, 
but to produce more than a moral effect they must be 
given in large doses. 

The treatment of the complications that may occur 
during these and the succeeding stages of gonorrhoea is 
considered elsewhere. 

ic) Stationary Stage. — When the inflammation has 
reached its acme it tends to persist unchanged for about 
a week or even longer. The treatment is that of the 
preceding stage, except that at this time the amount of 
copaiba or of sandalwood taken may be increased. Four 
doses a day should be ingested, beginning with about 
10 minims of the balsam of copaiba, or, if this is not well 
borne, lO minims of the oil of sandalwood, and the dose 
should gradually but steadily be increased until the 
symptoms improve or until the stomach will tolerate no 
more. Few can digest at a dose more than 20 or 30 
minims of either of these preparations. When such 
quantities have been given for a week without producing 
favorable results, it is wise to change or to try a combi- 
nation of the two ; or, if the discharge continue and the 
inflammatory symptoms be not high, some preparation of 
cubebs may be added. Local treatment is not yet indicated. 



ACUTE URETHRITIS. 409 

id) Stage of Decline. — If the discharge rapidly subsides, 
it is not wise to tax the stomach too severely with co- 
paiba or sandalwood, for fear of having to suspend their 
use altogether ; but if one of them has not already been 
pushed to the limit, now is the time to do so. As the 
discharge diminishes in amount and becomes less puru- 
lent and more mucous in character the copaiba may be 
dropped, and sandalwood oil or cubebs, or both, be sub- 
stituted. If under this treatment the discharge entirely 
ceases, the remedy in use at the time should be continued 
for another ten days, gradually decreasing the quantity 
until at the end of the time the patient may be taking 
only a small dose at night. All medication may now be 
stopped, and if at the end of another two weeks there is 
no discharge or other symptoms, and the drop of mucus 
squeezed from the deep urethra on several successive 
days show no gonococci, the patient may be allowed to 
return gradually to his accustomed habits of living. He 
must, however, be cautious in beginning the use of alcohol 
and tobacco, and for the unmarried sexual intercourse 
promises an added danger for some time to come, while 
the married must be careful not to indulge to excess. 

Injections. — The stage of decline is that which is most 
frequently prolonged, and if the discharge does not con- 
tinue to diminish under hygienic management and inter- 
nal treatment, injections may be used to advantage. 
Many habitually begin their use at the outset of this 
stage, but, as a rule, it is better to postpone the use of an 
injection until other treatment proves insufficient. While 
symptoms of inflammation persist, injections must be 
used, if at all, with the greatest caution, the strength of 
the liquid used being always in inverse proportion to the 
acuteness of the symptoms, otherwise there is danger of 



410 SYPHILIS AND THE VENEREAL DISEASES. 

producing an exacerbation of the existing trouble. Better 
a slow but steady disappearance of the discharge than a 
series of relapses from too energetic treatment. Injec- 
tions and other forms of local treatment should always 
be reserved as a last resort for a patient v/ho has had a 
posterior urethritis, an epididymitis, a prostatitis, or a 
cystitis complicating his gonorrhoea at any time during 
its course. The appearance of one of these complications 
during such treatment calls for its immediate suspension. 

Injections are used to greatest advantage when the dis- 
charge has been reduced to a thin muco-pus, or possibly 
to a few drops of mucus that appear only in the morning, 
but which refuse to disappear under other treatment. 
They are also indicated in cases of urethritis, of whatever 
origin, which run a subacute course and which do not 
respond to internal treatment and proper hygienic man- 
agement. These statements do not sanction the use of 
an injection in every case in which the lips of the meatus 
are adherent in the morning, or its prolonged use in cases 
where a morning drop or two at the meatus will not dis- 
appear after an injection has been used for a fortnight, or 
in cases which are not being otherwise properly managed. 
Frequently one injection after another is tried, the treat- 
ment being persevered in for weeks with the hope of re- 
moving the last traces of a discharge. It is well to 
remember that in these cases the local treatment may 
keep up the irritation, and that many patients recover as 
the result of merely stopping the injections. 

To inject the urethra properly calls for the right kind 
of a syringe and some skill, easily acquired by the major- 
ity, on the part of the patient. The syringe should hold 
from 2 to 4 drachms, though the urethra usually will hold 
less than two. The piston should fit tightly, to permit 



ACUTE URETHRITIS. 



411 



no leaking, but at the same time should move freely and 
easily within the barrel, and should have a ring at the 
end to receive the index finger. The nozzle should be 
a blunt cone, so that the tip, which should be perfectly 
smooth, will barely enter the meatus, and will not pro- 
ject into the urethra to irritate or damage the mucous 
membrane (Fig. 16). The syringe having a barrel of 




Fig. 16.— Urethral syringe. 



hard rubber with a soft-rubber tip fulfils these require- 
ments admirably. It is perhaps needless to add that 
the syringe should be scrupulously clean. 

To inject successfully, the patient should encircle the 
penis, just back of the corona, with the thumb and the 
forefinger of the left hand, exerting no more pressure 
than is necessary to enable him to extend the organ to 
its full length as the fluid is forced in. The syringe 
should be held in the right hand, with the tip of the 
index finger in the ring at the end of the piston, while 
the barrel is firmly held between the other three fingers 
and the thumb. With the penis gently drawn out to its 
full length, and with the tip of the syringe pressing into 
the meatus with just sufficient firmness to prevent leak- 
age, the fluid is slowly and steadily forced in until a slight 
ballooning or a feeling of fulness and tension in the urethra 
informs the patient that the urethra will hold no more. 
As the syringe is withdrawn the lips of the meatus are 
gently held together, retaining the medicament in the 



412 SYPHILIS AND THE VENEREAL DISEASES. 

urethra for about a minute before allowing it to escape. 
The whole procedure should be gentle ; any forcing of 
the fluid back of the compressor urethrse muscle into the 
deep urethra and the bladder is to be avoided. Slight 
pressure upon the piston is not dangerous, and no more 
is necessary. Injections may be used once, twice, or 
even three times a day, the last on retiring for the night ; 
but, should an injection cause much burning or pain, it 
must be allowed to escape at once, and before it is em- 
ployed again the fluid must be diluted largely. The 
patient should always first urinate, thus cleansing the 
urethra before each injection. 

Substances almost innumerable have been recom- 
mended and employed for urethral injections, but the 
skilful physician will select a few, usually not more than 
two or three, and learn to use them well. He becomes 
thoroughly familiar with their effects upon the varying 
stages and conditions of urethral inflammation, and 
accomplishes better and more definite results if he uses 
these few remedies, in varymg strength and frequency 
of application, than if he resort to others excellent in 
themselves, but with which he is less familiar. The fol- 
lowing are among the best : 

^. Liq. plumbi subacetatis dil., 3J ; 

Morphiae acetatis, gr. j. — M. 

This formula is recommended by Keyes for use in lesser 
stages of inflammation. In subacute cases the follow- 
ing are good: 

^. Potassii permanganat., gr. ss-j ; 

Aq. destilL, ij.—M. 



Or, 
Or. 



ACUTE URETHRITIS. 413 

!1^. Zinci sulphat, gr. j-ij ; 

Aq. destilL, ^j.— M. 

I^. Acid, tannic, gr. ij-vj ; 

Aq. destilL, Ij.— M. 



In ordering an injection it is well to advise at first a 
dilution with two or three times its bulk of water ; if 
this be ineffectual, and yet produce no irritation, the 
strength may gradually be increased. On the contrary, 
no injection should be continued which causes more 
than a slight smarting sensation while in the urethra and 
possibly for a few minutes afterward. The idea of 
" cauterizing " the urethra or " burning out " the disease 
has long since been abandoned. Injections are further 
considered in connection with the treatment of Chronic 
Urethritis. 

Summary of Treatment in Stages. — {a) Prodromal 
Stage. — Hygiene; alkali; guarded prognosis. 

(b) Increasing Stage. — Hygiene ; proper local dress- 
ing ; proper use of local hot and cold baths ; alkalies ; 
balsam of copaiba if well digested; if not, sandalwood 
oil, the dose of either being from 5 to 10 minims four 
times a day. 

{c) Stationary Stage. — Same as preceding, except that 
the dose of copaiba should steadily be increased to the 
point of improvement in symptoms or until the stomach 
begins to show signs of rebellion. If copaiba be not 
tolerated or be ineffectual, sandalwood oil is employed ; 
if both are well digested, but when given singly are 
ineffectual, they are to be combined. When the inflam- 
matory symptoms are mild, some preparation of cubebs 
may be added or substituted. 



414 SYPHILIS AND THE VENEREAL DISEASES. 

{d) Stage of Decline. — Same as preceding, except that 
as the discharge subsides copaiba is abandoned and 
sandalwood oil and cubeb preparations are substituted. 
If under this treatment the discharge persists in a sub- 
acute form, injections are indicated. Mild solutions are 
at first employed ; later, if necessary, the solutions may 
be increased in strength. 

The practitioner should never forget his patient while 
treating his patient's urethra. A feeble or cachectic sub- 
ject should not have a restricted diet that may still fur- 
ther reduce his strength and vitality. A man with a 
weak stomach should not swallow medicaments that 
induce marked digestive disturbances. No physician 
should persist in directing his efforts solely to the 
urethral discharge when the general condition of the 
patient calls for tonic or specific treatment. Sometimes 
a subacute urethritis in a feeble or cachectic individual 
refuses to subside under treatment ordinarily indicated 
in a urethritis of the same grade and character, but 
improves rapidly and disappears after the administration 
of iron, quinine, strychnine, cod-liver oil, or malt, 
together with fresh air and sunshine — in short, under 
such treatment as is called for by the general condition. 

Prognosis. — That gonorrhoea does not often directly 
threaten life is true ; but that it is as harmless as many 
young men, and even not a few inexperienced physicians, 
believe is far from true. Cases have occurred in which, 
as the result of poor hygienic surroundings or bad treat- 
ment, a high grade of inflammation has been followed 
by gangrene, septic infection, and death. Much more 
frequently death follows some of the complications of 
gonorrhoea, such as a prostatitis with prostatic or peri- 
prostatic abcess ; peritonitis following inflammation of 



ACUTE URETHRITIS. 415 

the seminal vesicles ; epididymitis ; cystitis ; pyelo- 
nephritis ; or, more remotely, gonorrhoeal rheumatism, 
endocarditis, or pericarditis. While the immediate 
danger to life is not so great, there is great danger that 
there will be left some form of chronic urethritis, stric- 
ture, chronic prostatitis, cystitis, vesiculitis, an ankylosed 
knee-joint, or an indurated epididymis which will render 
the affected testicle incapable of performing its function : 
if both epididymes have been involved, the man may 
for ever be denied the privilege of having children of 
his own. Or there may result some of the so-called 
" functional " and " nervous " disturbances of the genito- 
urinary system which so frequently undermine the tone 
of the entire nervous system, resulting in neurasthenia, 
hypochondriasis, and kindred obscure disturbances. 

The first attack of gonorrhoea, under proper manage- 
ment and in a healthy man, has a tendency to run a 
definite course toward recovery. It is quite unusual, 
however, for a patient with gonorrhoea to be so situated 
that all his surroundings are favorable to his complete 
recovery. Such a situation is difficult to obtain for any 
but those who for some other reason are compelled to 
remain in bed during the course of the disease ; and, as 
each successive attack exhibits a greater tendency to 
become chronic or to leave some portion of the urethra 
permanently damaged, the consequence is that but few 
urethras once infected with gonorrhoea ever return fully 
to their normal condition. Noeggerath believes that a 
man never fully recovers from his first gonorrhoea, and 
claims that nine-tenths of all women married to men 
who have ever had gonorrhoea eventually become suf- 
ferers from some form of pelvic inflammation. This is 
an extreme view, and one not yet fully accepted. The 



4l6 SYPHILIS AND THE VENEREAL DISEASES. 

question is further considered in connection with the 
subject of prognosis in Chronic Urethritis. 

The duration of a gonorrhoea under proper treatment 
depends so much upon the individual, his habits, his 
surroundings, and the previous state of his urethra, that 
it is impossible to make definite statements applicable 
to all cases. The prognosis must always be guarded. 
Usually the first attack of gonorrhoea, under favorable 
circumstances and with good treatment, lasts from five 
to eight weeks. The discharge may disappear or be 
suppressed by local treatment much earlier, but this fact 
by no means proves that the urethra is in a healthy 
condition or that slight irritation may not induce a dis- 
charge showing gonococci in abundance and proving 
highly infectious. Successive attacks, though less acute, 
are generally of longer duration. In general, an attack 
following a short period of incubation, in which the 
symptoms rapidly reach a climax of intensity, terminates 
in recovery earlier than another with a longer period of 
incubation in which the symptoms are subacute. 



COMPLICATIONS OF URETHRITIS. 



ACUTE POSTERIOR URETHRITIS. 

The term " acute posterior urethritis " is applied to 
inflammation of the membranous and prostatic portions 
of the urethra. The compressor urethrae muscle forms 
the dividing-line between the two anatomical divisions 
of the urethra, known as the anterior and posterior 
(or deep) urethra, or the pars anterior and the pars 
posterior. The pars anterior includes the bulbous and 
pendulous portions of the urethra; the pars posterior, 
the membranous and prostatic portions. The division 
is of importance from a pathological point of view, 
because of the close anatomical relations between the 
posterior urethra and the epididymis, prostate, bladder, 
and seminal vesicles. Inflammation of any of these 
organs is liable to occur with or after posterior urethritis, 
and when one of them is implicated the presence of 
posterior urethritis may be taken for granted. 

Etiology. — A posterior urethritis may appear any 
time after the third week of gonorrhoea, or before the 
third week in cases subjected to improper local treat- 
ment or which have not had proper hygienic manage- 
ment, or in cachectic and debilitated individuals. At 
any time during the course of gonorrhoea the extension 
of the inflammation to the pars posterior is favored by 
any mode of living or treatment that tends to congest 
or irritate this portion of the urethra. As a result of 
27 417 



41 8 SYPHILIS AND THE VENEREAL DISEASES. 

accident, of injury from instruments, of deep injections, 
of highly acid urine, or of fragments of calcuh, posterior 
urethritis may appear independently of inflammation of 
the pars anterior/ 

Symptoms. — About the end of the third week of 
gonorrhoea the inflammation, which in favorable cases 
has been limited to the pars anterior and should now 
begin to decline, may involve the pars posterior. This 
condition is usually announced by a more or less sudden 
increase in the frequency of urination, the patient some- 
times being compelled to urinate every few minutes. 
In severe cases the inflamed mucous membrane of the 
prostatic urethra becomes so sensitive and irritable that 
it will not tolerate the presence of the smallest amount 
of urine in the bladder, and but a few drops are required 
to excite an uncontrollable desire to urinate, the tenes- 
mus often being excruciatingly painful. 

A few drops of blood may appear at the close of each 
urination, or the hemorrhage may be considerable — some- 
times sufficient to pass backward into the bladder and to 
color all the urine. The perineum may be the seat of 
burning or cutting pains which may radiate to the end of 
the penis, to the testicles, the groins, or the back. In the 
majority of cases the symptoms are not so violent, and the 
patient complains only of a feeling of pressure and dis- 
comfort, with possibly burning, tickling, or slight pains in 
the perineal region, together with a more or less increased 



^ Many authorities now claim that posterior urethritis is not a comphca- 
tion, but a natural sequence, of gonorrhoea; that it is present in the large 
majority of acute cases ; and that it usually appears during the first week 
— as a rule, without marked symptoms and independently of local treat- 
ment. The questions of etiology, diagnosis, and treatment are at present 
the subject of active investigation and discussion. 



ACUTE POSTERIOR URETHRITIS. 419 

frequency in micturition. There is usually considerable 
irritation of the sexual organs, manifested in prolonged 
and painful erections at night, and in frequent seminal 
emissions, which may be mixed with blood. 

When the inflammation involves the posterior urethra 
the process in the anterior portion often subsides to a 
great extent, with marked diminution in the discharge 
from the meatus ; and though the reverse may be true, 
yet the sudden cessation of a gonorrhoea! discharge 
should always lead one to suspect this complication. 
The acute symptoms in a posterior urethritis usually 
last but a few days, but the process is generally pro- 
longed in a subacute form and shows a decided tendency 
to become chronic. 

Diag-nosis. — The occurrence, during gonorrhoea, of 
frequency of urination, tenesmus, hemorrhage, or the 
sudden cessation of the discharge, should lead one to 
examine for posterior urethritis. The finger in the rec- 
tum finds the prostatic and membranous portions of the 
urethra sensitive ; slight pressure increases the pain and 
tenesmus, but the prostate is not enlarged. Examina- 
tion with instruments in the urethra is contraindicated, 
but the urine should be examined carefully by Thomp- 
son's two-glass test. This test is based on the supposi- 
tion that pus secreted in the prostatic urethra cannot 
pass the compressor urethrse muscle and find its way 
out through the pendulous portion; but, on the contrary, 
if more pus collects than the prostatic urethra can hold, 
it will pass back into the bladder and mingle with the 
urine, rendering the latter cloudy. If the patient passes 
the contents of his bladder in two glasses, the first glass 
will contain urine plus the washings of the urethra, 
while the second will contain the urine as it exists in the 



420 SYPHILIS AND THE VENEREAL DISEASES. 

bladder. If this second portion is clouded by the 
presence of pus, the latter evidently comes from some 
portion of the genito-urinary tract back of the compres- 
sor urethrae muscle. 

The exact localization of the source of pus in 
the bladder is often difficult and calls for careful 
microscopical examination, but the presence, during 
the course of gonorrhoea, of pus in the second glass, 
together with the occurrence of the above-described 
symptoms, will point strongly to posterior urethritis. 
If the urine is passed frequently, there may be times 
when no more pus will accumulate than the prostatic 
urethra can hold (when it will all be washed out with 
the first urine), so that the urine in the bladder will re- 
main clear and will appear so in the second glass. This 
occasional appearance of clear urine in the second glass 
will exclude cystitis. In less acute cases, since the 
amount of pus produced is small, the urine in the second 
glass may always be clear unless the urine has been re- 
tained in the bladder three or four hours. It is import- 
ant, consequently, that the morning urine — also that 
passed at the time of the visit — be examined. The 
degree of cloudiness and the amount of pus m the urine 
of the second glass give some indication of the intensity 
of the inflammation.^ 

Treatment. — The general hygienic management is 
that of gonorrhoea, except that rest is of still greater 

^ The only cloudiness of urine considered in these pages is that pro- 
duced by pus and mucus. The nature of the sediment in any specimen 
of turbid urine should be determined by the usual methods of urinalysis or 
microscopical examination. Gentle heat clears a turbidity due to the 
presence of urates; acetic acid, that caused by phosphates or carbonates; 
bacteria and pus can be removed only by filtration. 



ACUTE POSTERIOR URETHRITIS. 42 1 

importance, and in severe cases with much tenesmus or 
hemorrhage rest in bed, or at least in the recumbent 
position, is absolutely necessary. Large quantities of 
bland fluids, such as flaxseed or slippery-elm tea, should 
be drunk, and the urine should be rendered sterile b}' 
the use of boric acid, salol, or salicylate of sodium, in 
doses of from 5 to 10 grains four times a day. Since 
marked alkalinity of the urine would favor ammoniacal 
decomposition in the bladder, it is best to keep the urine 
neutral, and the dose of alkalies, if given at all, should 
be small. Copaiba and sandalwood are valuable in most 
cases, but they may prove irritating, and should then be 
stopped. If the urine is markedh' alkaline and contain 
pus, it may be advisable to give benzoate of ammonium 
in small doses sufficient to keep the urine neutral, but if 
given too freely it will prove a source of irritation. 

For the purpose of controlling the pain and tenesmus, 
suppositories containing morphine (gr. ]/^) and atropine 
(gr. g^) may be used in the rectum, or from i to 10 
minims of the fluid extract of hyoscyamus may be given 
every few hours. The use of a catheter is to be avoided 
if possible, and is rarely necessary if the directions 
given for the treatment of retention of urine in gonor- 
rhoea be faithfully followed. Allowing the patient to 
urinate while sitting in a tub of hot water will rarely fail 
to give better results than the catheter. If the posterior 
urethritis has come on durincr the declinincj" staa"e of 
gonorrhoea, or if for any reason local treatment of the 
anterior urethra has been instituted, such treatment must 
be suspended at once. If local treatment is to be tried, 
it should be in the form of a direct application to the 
deep urethra. The methods are described under treat- 
ment of Chronic Urethritis. 



422 SYPHILIS AND THE VENEREAL DISEASES. 

EPIDIDYMITIS. 

With the exception of posterior urethritis, epididymi- 
tis is the most frequent compHcation of gonorrhoea. It 
occurs in from 6 to 15 per cent, of all cases of acute 
gonorrhoea, and it usually makes its appearance during 
the third or fourth week of that disease. It frequently 
begins as late as the eighth week, and it may occur 
much later, though most of the cases appearing some 
months or years after an attack of gonorrhoea are un- 
doubtedly due to an exacerbation of a chronic urethritis, 
to stricture, or to other causes. It is also found as early 
as the second week, and cases are reported as beginning 
during the first week, of gonorrhoea. 

The epididymitis is usually single, the left testicle being 
involved somewhat more frequently than the right. When 
both testicles are implicated, the second follows several 
days or weeks after the first, simultaneous epididymitis 
of both testicles being very rare. The first attack is 
usually acute, and predisposes the patient to the disease, 
which may thus become chronic. Occasionally, in 
cachectic subjects or when due to stricture or chronic 
urethritis, it may be subacute from its origin. It is 
usually accompanied by inflammation of the tunica 
vaginalis, and less frequently by orchitis. 

Etiolog-y. — Epididymitis occurs during acute gonor- 
rhoea without other apparent cause. It is more frequent 
in neglected and poorly-treated cases than in those 
treated in accordance with the hygienic and other rules 
given for the treatment of gonorrhoea. Any of the 
causes mentioned as capable of producing an exacerba- 
tion of the urethritis or irritation of the urethra may 
increase the danger of epididymitis. It is probably 



E FID ID YMITIS. 423 

alwa3^s preceded by inflammation of the pars posterior, 
from which position the inflammation travels readily and 
continuously through the ejaculatory ducts and the vas 
deferens to the epididymis : evidences of inflammation 
of these intermediate parts are often wanting, and it is 
possible that in some cases the lymphatics convey the 
infection directly from the deep urethra to the epididy- 
mis. Some writers speak of reflected irritation as a 
sufficient cause. Some individuals are very susceptible 
to the disease, while others seem proof against it, 
despite neglect, reckless living, and poor treatment. 
One attack always predisposes to another. It occurs in 
subacute and chronic (also acute) forms in chronic 
gonorrhoea and stricture, especially when these con- 
ditions have been aggravated by improper treatment^ 
disordered living, violent exercise, etc. Finally, it may 
occur independently of urethral disease, as a result of 
traumatism, or possibly from prolonged sexual excite- 
ment or exposure to cold. 

Symptoms. — In observant and sensitive patients, and 
especially if the previous subjective symptoms of gonor- 
rhoea have been slight, the inflammation of the epidid- 
ymis is usually preceded by prodromal symptoms in the 
way of slight chills, fever, and malaise, with vague, un- 
easy sensations or slight pain in the groin and radiating 
to the kidneys and the testicle. Occasionally the ingui- 
nal pain is severe, and the cord is tender and feels as 
though it were suspending a heavy weight ; or there may 
be a sensation of pressure in the perineum, with vesical 
tenesmus and difficulty in urination. Less frequently, 
inflammation and swelling of the cord are recognized for 
several days preceding an epididymitis ; and in rare in- 
stances the process is limited to the cord. 



424 SYPHILIS AND THE VENEREAL DISEASES. 

In unobservant individuals and in those already suffer- 
ing considerable inconvenience and distress from gonor- 
rhoea the prodromal symptoms frequently pass un- 
noticed. In such cases the lirst recognized evidence of 
the complication is usually a sudden decided pain in the 
affected testicle. If examined at this time, some por- 
tion of the epididymis, usually the globus minor or 
major, is found to be slightly swollen and very tender. 
During the next twenty-four hours the pain and swelling 
increase rapidly ; the entire epididymis soon becomes in- 
volved, and can be felt as an irregular, well-defined, 
moderately firm, half-moon-shaped tumor enclosing the 
superior, posterior, and inferior borders of the testicle. 
It is very painful, especially when the testicle is allowed 
to hang w"ithout support, and is exceedingly tender to 
the touch. Under favorable circumstances or with good 
treatment the disease may progress no further, and after 
a few days the symptoms will begin to subside : this 
result is not common even wdth the best treatment. 

More frequently the inflammation extends from the 
epididymis to the tunica vaginalis, which becomes more 
or less distended wath fluid, thus adding greatly to the 
swelling and pain and partially or wholly obscuring the 
outline of the epididymis and testicle. The testicle 
proper becomes engorged and distended with blood, and 
occasionally true orchitis (which terminates in resolution), 
with its intense and characteristic pain, may be present. 
The loose tissues of the scrotum become inflamed, oedem- 
atous, and swollen, sometimes forming irregular, thick- 
ened tumors that may be carelessly taken for the inflamed 
testicle itself The testicle with its epididymis and their 
coverings thus form an irregular or oval tumor that may 
become larger than a man's fist, reddened, hot, exceed- 



EPID ID YMITIS. 425 

ingly painful, and tender. The cord may become swollen 
and very painful, often drawing the testicle up toward the 
groin ; in rare instances it becomes partly strangulated in 
the inguinal canal, resulting in intense pain, collapse, 
and all the symptoms common to strangulation with in- 
flammation. 

The intensity of the symptoms, however, varies greatly 
in different cases. The swelling may be limited to a part 
or all of the epididymis, which is more or less indurated 
and tender, or it may be increased by fluid in the tunica 
vaginalis. This fluid may be scanty in quantity and may 
serv^e merely to form a fluctuating tumor which but par- 
tially obscures the outline of the testicle and epididymis, 
or it may be sufficient to forcibly distend the cavity, 
forming a tense, exceedingly painful tumor which con- 
ceals entirely all traces of the enclosed structures. Swell- 
ing and infiltration of the scrotal tissues may be slight, 
but they are" usually marked and are often sufficient to 
make an examination of the deeper parts impossible. 
As a result of ill-fitting dressings, swelling of the scrotum 
may be pronounced in cases that are otherwise mild. 

The pain in epididymitis varies greatly, but in acute 
cases it is usually intense. The organ is very sensitive, 
and the slightest pressure upon it causes the patient to 
feel nauseated and faint. Without proper support for the 
testicle walking is often impossible. Absolute rest and 
support of the scrotum in one groin or over the pubis 
lessens, but does not entirely remove, the pain. If there 
be much inflammation of the testicle proper or strangu- 
lation of the cord — both uncommon occurrences — posi- 
tion has little influence on the pain, which is even more 
intense than in epididymitis, and it may be compared to 
that of renal colic. A similar but less severe grade of 



426 SYPHILIS AND THE VENEREAL DISEASES. 

pain is produced when the tunica vaginaHs is greatly dis- 
tended, but usually the most tender part is the epididy- 
mis, which can thus be located by palpation even through 
a swollen and oedematous scrotum. 

The course of the disease varies considerably, being, 
as a rule, much shorter and more even when the parts 
are put at rest and given proper treatment than in cases 
in which such rest and good management cannot be 
obtained. It is further influenced by the idiosyncrasies 
and general health of the patient. In an acute case the 
symptoms usually increase rapidly in severity for three 
or four days or a week, remain stationary for a few days 
more, and then decline, so that at the end of ten days 
or two weeks from the beginning the pain is practically 
gone and the swelling is limited chiefly to the epi- 
didymis, some portions of which are still indurated and 
tender. An uncomfortable sense of weight and sore- 
ness may remain for some time. 

From the beginning, if the patient be kept on his 
back and the scrotum be well supported, the pain usually 
subsides rapidly, and it may become slig-ht before the 
swelling has begun to disappear ; but if he sit or stand 
and allow the testicle to depend, the pain promptly re- 
turns. As the pain subsides the patient often thinks 
himself able to get up and return to his business, but a 
few hours or a day of ordinary activity may send him 
to bed with the pain and swelling nearly as severe as 
before. Even at the end of two weeks, when he seems 
to be practically well, if he is very active and fails 
properly to support the testicle, a relapse may be ex- 
pected. Relapses are not uncommon, and, while less 
severe than the first attack, may prolong the disorder 
indefinitely and result in a permanent induration of the 



EPIDID YMITIS. 427 

globus minor or major. As a rule, the globus minor, 
or less commonly the globus major, remains more or 
less swollen, indurated, and tender for some weeks ; 
while th'e last traces of induration disappear gradually 
in the course of months or years, or persist permanently 
in the form of a hard, insensitive nodule. 

For a few days during the height of the attack there 
is usually some fever with its attending symptoms ; such 
constitutional disturbances are usually mild, but occa- 
sionally they are quite severe. The gonorrhoeal dis- 
charge, which commonly diminishes with or just pre- 
vious to the appearance of the swelling, may disappear 
entirely, but it returns when the swelling subsides. 

Subacute attacks occasionally complicate stricture or 
gleet The symptoms come on more slowly, are much 
less severe than in the acute form, and are usually con- 
fined to the epididymis or some portion of it and to the 
cord. The testicle, the tunica vaginalis, and the scrotum 
are not at all or but slightly involved, and constitutional 
symptoms are wanting. The epididymis, and frequently 
the cord, is somewhat swollen, tender, and sensitive, but 
a well-fitting suspensory or other support usually enables 
the patient to attend to his usual work without much 
discomfort, though violent exercise should be avoided. 
As in gonorrhoea, the gleety discharge disappears dur- 
ing the swelling, to return as the latter subsides. 

As a result of repeated subacute attacks or of relapses 
in acute epididymitis, the inflammation may become 
chronic. Portions of the epididymis are then constantly 
swollen, thickened, and tender, simulating tuberculosis 
of the organ, except that the nodular enlargements are 
smoother and less irregular in outline, and that slight 
causes suffice to produce a subacute inflammation of the 



428 SYPHILIS AND THE VENEREAL DISEASES. 

entire body of the epididymis. The cord and the con- 
nective tissue about it may also be swollen, infiltrated, 
and sensitive, and may be the seat of neuralgic pains. 
Exceptionally there is chronic suppuration in portions 
of the inflamed tissues. 

Diag-nosis. — The characteristic symptomiS appearing 
during the course of a gonorrhoea usually render the 
diagnosis easy. Orchitis, the only other disorder for 
which it might be mistaken, is rare and is not associated 
with urethral inflammation, but is caused by injuries, 
mumps, cold, and constitutional disorders. The swell- 
ing in orchitis involves the testicle proper, comes on 
more slowly, and forms a smaller tumor which is oval, 
smooth, peculiarly hard and tender, and not obscured 
by fluid in the tunica vaginalis. The pain is more in- 
tense and unbearable than in epididymitis, and is not 
influenced by position. Its course is slower, and it may 
result in destruction of portions or of all of the testicle 
through atroph}', suppuration, or gangrene. 

Cases have been reported in which epididymitis of 
an undescended or abnormally situated testicle has been 
mistaken for strangulated hernia, etc. Such an error 
can be avoided by an examination of the scrotum, which 
would show the absence of one testicle. There have 
also been reported cases in which the inflammation has 
been limited to the vas deferens, with the formation of 
a rounded painful tumor extending from the ring to the 
epididymis. There are on record a few cases in which 
an ordinary epididymitis has been preceded by partial 
strangulation of the cord, with symptoms suggesting 
strangulated hernia or obstruction of the bowel with 
peritonitis. 

Treatment. — Since epididymitis is almost invariably a 



EPIDIDYMITIS. 429 

complication of urethral inflammation, its prophylactic 
treatment lies in th proper hygienic and other manage- 
ment of the primary disorder. If an individual has had 
a previous epididymitis, he should wear, during the 
course of his gonorrhoea, a well-fitting suspensory band- 
age, live as quietly as possible, and avoid active exercise 
(especially lifting, jumping, dancing, etc.) and all irritation 
of the sexual organs, following faithfully the hygienic rules 
given for the treatment of gonorrhoea. Epididymitis can 
sometimes be prevented if, upon the first appearance of 
pain or uncomfortable sensations in the testicle or the 
groin, the patient lie on his back, with the scrotum ele- 
vated and covered for a few hours with hot applications. 
In acute cases of epididymitis the objects of treatment 
are to lessen the inflammation and pain and to promote 
resolution. The essential requirements are complete rest, 
elevation and support of the testicle and scrotum, and the 
application of heat. A light diet and simple laxatives to 
produce free evacuation from the bowels constitute the 
only internah treatment, unless the condition of the in- 
dividual calls for special medication. All treatment for 
gonorrhoea, except that necessary to keep the urine bland, 
should be suspended. The patient should rest quietly 
on his back. The scrotum should be covered completely 
with fomentations or poultices, and should be supported 
carefully, by means of a sling or a bandage, in a com- 
fortable position over the symphysis or in one groin. 
The most satisfactory bandage for this purpose is the last 
of those recommended for dressing the organs during 
gonorrhoea, as it can easily be made to fit a testicle and 
its dressing of any size or shape. Another simple device 
is found in a large handkerchief or napkin folded once to 
form a triangle ; the middle of the long (folded) side is 



430 SYPHILIS AND THE VENEREAL DISEASES. 

placed under the scrotum, and an end (acute angle) is 
fastened on each side to a belt made of any convenient 
and comfortable material. The free (right) angle is 
brought up over the genitals and dressings and fastened 
to the belt in front. To keep the handkerchief from 
slipping upward it may be necessary to sew to its pos- 
terior border a narrow band that can be pinned to the 
belt behind. 

Heat is best applied by means of fomentations, which, 
when skilfully employed, are more effective than poultices, 
and, being light, are often more comforting to the patient, 
for in a severe case the testicle may be so sensitive that 
the weight of a poultice cannot be tolerated. They may 
be made of a number of layers of gauze, or of from one to 
four thicknesses of a light white flannel faced with a piece 
of gauze, linen, silk, or cotton, which will be less irritating 
to the skin than the flannel. They should be large 
enough to more than cover the scrotum completely, and 
they should be covered in turn by a larger piece of oiled 
silk or of rubber tissue, which will serve to retain the heat 
and to keep the clothing dry. They should be applied 
as hot as the patient can tolerate them with comfort, and 
should be changed often enough to keep them hot (from 
once in half an hour to once in two hours). Two sets 
of cloths are necessary, that one may be hot and ready 
for immediate application when the other is removed, as 
much harm may be done by having the parts exposed to 
a lower temperature while preparing the fomentation. It 
is equally important that in making changes the testicle 
be moved or disturbed as little as possible. The cloths 
may be wrung out of simple hot water, but it is better to 
add a teaspoonful of boric acid to each pint of water. 

When the patient has neither the assistance nor the con- 



EPIDID YMITIS. 43 I 

veniences necessary for the frequent application of fomen- 
tations, an ordinary flaxseed poultice may be substituted. 
This poultice should be from a quarter to half an inch 
thick, faced with a thin soft cloth to keep the wet meal 
from adhering to the scrotum, and the whole should be 
covered with oiled silk. Poultices retain the heat longer 
than fomentations, and need not be changed so frequently 
(from once in four hours to once in eight hours). 

In the majority of cases a few hours of the above treat- 
ment will make the patient comfortable while he remains 
quiet. If these measures do not give relief, from \ ounce 
to I ounce of fine-cut tobacco should be stirred thor- 
oughly in a pint of the boiling water which is to be used 
for fomentations or poultices. This is a very effective 
anodyne, but it may produce nausea. Instead of tobacco, 
lo grains or more of powdered opium to the pint of 
water may be used. Sometimes sprinkling the surface 
of the fomentation or the poultice with fine-cut tobacco 
or with laudanum gives good results. Other anodynes 
may be applied, under the poultice, in the form of powder, 
liquid, or ointment, but they are rarely needed. If these 
measures are not sufficient, and if the pain be due to ex- 
treme distention of the tunica vaginalis, puncture will 
allow of escape of the fluid and will give immediate relief 
In exceptionally acute cases, with strangulation of the 
cord and extreme pain which is not relieved by the usual 
treatment, ten or more leeches may be applied above the 
groin, along the course of the cord, followed by the use 
of hot water to encourage bleeding: the effect on the 
pain is often prompt and decided. 

In all cases of epididymitis, when the patient can afford 
the time, rest in the horizontal position and elevation of 
the scrotum should be continued for ten days or two 



432 SYPHILIS AND THE VENEREAL DISEASES. 

weeks, or until all symptoms have disappeared except a 
small, tender, indurated swelling of the globus minor. 
The fomentations or poultices hasten absorption of the 
inflammatory products, and should be continued when 
practicable, though after the first few days, when the 
symptoms have begun to subside, they may be replaced 
by a more convenient and nearly as efficient dry dressing 
formed by wrapping the scrotum in a layer of wool and 
covering all closely with an impervious covering of oiled 
silk or of rubber tissue. The heat and moisture natural 
to the parts are thus retained, forming what is known as a 
** dry poultice." 

When a patient with acute epididymitis refuses to go 
to bed for a few days, other methods may be tried ; but 
he should first understand that his recovery will be 
slower and that a permanent induration of the globus 
minor and obstruction of the vas deferens will probably 
follow. The scrotum over the affected testicles may be 
smeared lightly with an opium-and-belladonna ointment, 
covered with a " dry poultice," and the whole supported 
and made as immovable as possible with the wide band- 
age already recommended, or — what is often more effec- 
tive when the patient is on his feet — with the Horand- 
Langlebert suspensory, which may be obtained from the 
makers of surgical appliances. By avoiding sudden and 
rapid movements the patient is often enabled to move 
about with comparatively little discomfort. For these 
cases Dr. W. S. Halstead and others touch the surface of 
the scrotum lightly in several places with the point of 
the cautery at a white heat ; iodoform ointment is then 
applied, and the testicle is properly supported. This 
method frequently relieves the pain and allows the 
patient to remain up and to move about. Tincture of 



E FID ID YiMiriS. 43 3 

iodine and strong solutions of nitrate of silver have been 
used to paint the scrotum and to produce counter-irrita- 
tion, but they usually fail to do much good, and they 
often cause a severe dermatitis of the scrotum. 

When possible, every patient with epididymitis should 
be kept on his back until the pain has subsided and the 
swelling has been reduced somewhat (from three to 
eight days) ; but if he is then unwilling to spend more 
time in bed, he may be allowed to rise and go about 
if his testicle is first properly strapped. To determine 
if a testicle is ready for strapping, the organ is taken in 
the hand and gently manipulated for several minutes, 
gradually bringing the testicle to the bottom of the 
scrotum, which is encircled, just above the testicle, by 
the thumb and forefinger, forming a ring which gentle 
pressure is making gradually narrower. These manipu- 
lations will probably cause some pain in the testicle or 
in the groin, but this pain will usually disappear without 
relaxing the pressure if the operating hand be held mo- 
tionless for a few seconds. If the pain is but slight 
when the ring formed by the thumb and the finger is too 
small for the testicle to escape through it upward, and 
the testicle is thus secured in a smooth, tense, and shin^ 
ing pouch of the scrotum, strapping is proper. 

For strapping the testicle rubber adhesive plaster or 
lead-plaster may be used, in strips half an inch wide. 
The hairs should be cut from the scrotum, to prevent 
their being pulled by the plaster on its removal. The 
most difficult and most important part of the whole pro- 
cedure lies in applying the first strip of plaster, which 
must be made to take the place of the thumb and the 
finger in forming a ring to hold the testicle in the posi- 
tion described above. The strip should be half an inch 

28 



434 SYPHILIS AND THE VENEREAL DISEASES. 

wide and three or four inches longer than necessary to 
encircle the testicle. To its under (adhesive) surface is 
fastened a cotton bandage an inch and a half wide and 
enough shorter than the plaster to leave one end of the 
latter uncovered for two or three inches. The bandage 
is used to prevent the edge of the plaster from cutting 
the scrotum. 

The patient stands, or sits on the edge of a chair, 
in front of the operator, who has taken the precaution 
to have his strips of plaster, bandage, scissors, etc. 
ready and within easy reach. When the left hand has 
once more secured the testicle in the desired posi- 
tion, the pressure may be relaxed without changing the 
position of the hand, and the prepared adhesive strip is 
placed around the scrotum in the position just vacated 
by the thumb and the finger. The thumb and the finger 
again encircle the scrotum above and outside of the 
adhesive strip, holding the end covered by the bandage 
in position and forcing the testicle down, wdiile the right 
hand brings around the free end of the plaster and fastens 
it to the back of the fixed end. If properly done, the 
testicle is secured in a smooth, tense, purplish pouch 
of the scrotum, the adhesive strip forming a ring too 
small to allow the escape upward of the testicle. After 
waiting two or three minutes to allow the pain to sub- 
side (as it will do if the plaster be not drawn too tight), 
the operator applies several more circular strips parallel 
with the first, each strip overlapping the one last applied 
by about half its width. When strips applied in this 
direction will no longer fit the surface, others may be 
fastened to the first strip on one side, carried over the 
testicle, and fastened to the first strip on the opposite 
side, until the entire surface below the ring is firmly and 



E PI DID YMITIS. 435 

completely covered. A long circular strip should finally 
be applied to cover and hold the ends of the strips last 
applied. When finished the covering should exert even 
pressure upon the entire surface, thus encouraging ab- 
sorption and preventing the possibility of a return of the 
swelling. 

It is always best to have the patient rest quietly 
for half an hour or more after strapping the testicle, 
until the pain caused by the manipulations has dis- 
appeared, when he can support the scrotum with a 
suspensory bandage (made to fit by lining it with cotton), 
and go about his business in comfort and without fear 
of a relapse. If the dressing remains painful after an 
hour, or if it becomes so at any time, it should be re- 
moved either by cutting the separate strips or by im- 
mersing the whole in hot water until it can be slipped 
off Pain will follow strapping if the testicle is not ready 
for it, if the ring formed by the first strap be too tight, 
or, as frequently happens, if the ring be so large that the 
testicle is forced partially into it by the other straps. 
At the end of from twenty-four to fbrt3^-eight hours the 
swelling will have been so reduced in size that the dress- 
ing no longer exerts pressure upon the testicle, which 
sometimes escapes through the ring, and a new strap- 
ping is necessary. The procedure is repeated four or 
five times until all that remains of the swelling is the 
indurated globus minor. 

For several weeks, until all swelling is reduced to a 
painless induration, a well-fitting suspensory should be 
worn. This is done to prevent a relapse and to hasten 
absorption, a process that may be aided by daily inunc- 
tion over the nodule with oleate of mercury (2 to 10 
per cent.), and by lining the suspensory with oiled silk 



436 SYPHILIS AND THE VENEREAL DISEASES 

and a thin layer of wool to form a light " dry poultice." 
Too early suspension of treatment, and especially of 
support for the parts, may lead to chronic inflammation 
of the epididymis and the cord. 

The treatment of subacute and chronic epididymitis 
is that of the declining stages of the acute process. In 
addition, all predisposing and exciting causes should be 
removed. 

Prog-nosis. — Epididymitis almost always terminates 
in resolution ; suppuration is very rare except in the 
uncommon chronic cases. Absorption of inflammatory 
products is rapid at first, and at the end of a few weeks 
of good treatment all pain and tenderness have dis- 
appeared, and there remains only some swelling and 
induration of the globus minor or major. This remain- 
ing induration may require months or years for its final 
absorption, and frequently persists permanently in the 
form of a hard nodule found to be composed of inflam- 
matory deposits in and surrounding the seminal canals, 
which are thus completely occluded. 

Permanent induration is most common in the globus 
minor, and, as this body is composed of the convo- 
lutions of a single tube, the blocking of any portion 
of it prevents the passage of the semen from the 
testicle proper to the vas deferens. Even when all 
apparent induration has disappeared, and this portion 
of the epididymis again feels normal to the palpating 
finger, the canal may be filled and obstructed at some 
point. Complete absorption of the deposit and re- 
opening of the canal in the globus minor can be ex- 
pected in but a small minority of cases. In the globus 
major complete absorption is more common, and even 
if it does not occur, some of the tubules may escape 



PR OS TA riTis. 437 

obstruction. It follows that the large majority of men 
who have had epididymitis on both sides are sterile. 
The cause of their sterility lies solely in mechanical 
obstruction to the passage of semen, since the testicle 
does not atrophy nor is the man impotent. He retains 
his sexual appetite and power, and ejaculates a fluid 
resembling semen except that it contains no sper- 
matozoa. 

In a tubercular or syphilitic patient epididymitis may 
be followed by the appearance of the constitutional 
disease in the epididymis. 

Subacute and chronic cases of epididymitis terminate 
favorably when proper treatment is continued for a 
sufficient period. 

PROSTATITIS. 

I. Acute Prostatitis. — When gonorrhoeal inflamma- 
tion reaches the posterior urethra, it frequently includes 
the superficial glands and follicles of the prostate, and 
it may readily involve the entire structure of the organ. 
Prostatitis commonly appears after the third week of 
gonorrhoea, its symptoms following or appearing simul- 
taneously with, and possibly obscuring, those of pos- 
terior urethritis. It occurs also with chronic urethritis 
and with stricture. The exciting causes are practically 
those of posterior urethritis and epididymitis — -namely, 
coitus; prolonged or intense sexual excitement; violent 
exercise ; excessive use of alcohol, tobacco, or highly 
seasoned foods ; exposure to cold ; and mechanical or 
chemical injury due to the use of instruments or injec- 
tions, or possibly to a concentrated and irritating urine. 
It is possible that these causes may produce prostatitis 
independently of gonorrhoea. 



438 SYPHILIS AND THE VENEREAL DISEASES. 

Symptoms. — Folliadar Prostatitis. — If the inflamma- 
tion be limited to a few follicles, the symptoms will be 
those of posterior urethritis, with the probable addition 
of sharp, sticking pains most noticeable at the close of 
urination. The finger in the rectum may find one or 
more firm, tender nodules in the substance of the pros- 
tate, which is possibly somewhat congested and slightly 
swollen, but not inflamed or very sensitive. These in- 
flammations may undergo resolution, the s}'mptoms 
disappearing with those of the posterior urethritis ; or 
they may extend to the rest of the prostate ; or, finally, 
they may linger indefinitely in the form of a chronic 
folliculitis. 

Diffuse or Parenchymatous Prostatitis. — In this form of 
prostatitis the symptoms are much more pronounced 
and characteristic. The prostate swells rapidly, notwith- 
standing the fact that it is surrounded by a firm, fibrous 
capsule, and the resulting pressure to which the inflamed 
organ is subjected produces violent pains and interferes 
greatly with the urinary and sexual functions. There is 
frequency of urination, tenesmus, and the patient ex- 
periences a feeling of fulness and warmth in the rectum, 
producing an almost constant desire to empty the bowel, 
and leading him to make frequent and often violent 
efforts to expel what he thinks is a mass of faeces, but 
which is really the swollen prostate protruding into the 
rectum. Defecation is painful, and there may be tenes- 
mus of the bowel. Urination is also painful, especially 
at the close of the act, when the patient may experience 
violent sharp pains due to the squeezing of the tender 
prostate by the sphincter vesicae muscle, and the last 
drops of urine may be mixed with blood. The stream 
of urine is often reduced in size, and the pressure upon 



PROSTATITIS. 439 

the prostatic urethra maybe sufficient to cause complete 
retention. 

In addition to the subjective sensations already 
described, the patient complains of fulness, pressure, 
weight, and pain in the perineum, which may be hot 
and so tender that the sitting posture or crossing of 
the legs cannot be endured. The pain is variously 
described by patients as sharp, lancinating, shooting, 
borin«", or throbbing; in character, and radiates from the 
prostate and perineum to the urethra, testicles, thighs, 
and back. With the finger in the rectum the prostate is 
outlined as a firm, hot, pulsating, more or less irregular 
tumor, which is exceedingly sensitive to pressure, and 
which in severe cases may become almost as large as a 
man's fist, and may entirely occlude the rectum. 

The disease is usually accompanied from the begin- 
ning with some fever and constitutional disturbance, and 
by diminution or cessation of the urethral discharge 
during the swelling of the prostate. A marked feature 
of prostatitis, and one for which the inexperienced prac- 
titioner is rarely prepared, is the mental attitude of the 
patient, whose restlessness, fears, and anxiety are out of 
all proportion to the severity of the process. As Keyes 
well says : " The patient is irritable, despondent, and 
suspicious, often, in fact, wild to an extent amounting to 
mild acute mania." He is inclined to be dissatisfied with 
all that is done for him — in short, is usually a very un- 
satisfactory patient to treat during the acute process, 
unless he can have a constant attendant to watch over 
him and properly to carry out the physician's orders. 

The course of the disease, when it ends, as it com- 
monly does, in resolution, is short; the symptoms 
appear more or less suddenly, rapidly increase to the 



440 SYPHILIS AND THE VENEREAL DISEASES. 

highest point, and ahnost as rapidly subside, so that the 
acute stage varies in duration from four to ten days, and 
final recovery follows in another week or two. As the 
symptoms subside and the urethral discharge reappears, 
the latter may at times be changed in character by ad- 
mixture with a thick, viscid mucus and pus from the 
prostatic follicles ; and if the seminal vesicles have been 
involved, the discharge may contain a i^^N spermatozoa. 
Instead of undergoing resolution, the inflammation 
may go on to suppuration involving portions or all of 
the prostate. The formation of pus is usually an- 
nounced by a decided chill and a marked increase in 
temperature, and the constitutional disturbance may be 
considerable. The feeling of tension in the perineum is 
usually diminished, and the pains may lose their intense, 
boring character and become cutting and throbbing. 
Retention of urine commonly results. Fluctuation can 
sometimes be felt through the rectum. If untreated, 
these abscesses rupture into the urethra, the rectum, or 
the perineum, the order of frequency being that given. 
Exceptionally, they extend beyond the limits of the 
prostate, burrow extensively between the layers of the 
pelvic fascia, and open into the ischio-rectal fossa, the 
inguinal region, or even into the peritoneum, and may 
cause death from sepsis or from peritonitis. Occasion- 
ally an abscess will discharge into both urethra and 
rectum or into the urethra and some other region, as the 
perineum, and result in urinary fistula. Rupture of the 
abscess brings immediate relief from pain ; if the abscess 
be a small one, opening into the urethra, it will usually 
fill with granulations and slowly heal. An opening into 
the rectum is unfavorable, since the cavity is more liable 
to infection and can be kept clean only with great difficulty. 



PROSTATITIS. 441 

Occasionally during gonorrhoea, stricture, or conse- 
quent inflammation of the seminal vesicles or of the vas 
deferens, suppuration may occur in the tissues surround- 
ing the prostate (periprostatic abscess). As these ab- 
scesses are situated in looser tissues, their symptoms are 
less acute than in prostatic abscess, and the finger in the 
rectum locates them outside the capsule of the prostate ; 
but in other respects their course is practically that of 
prostatic abscess. 

Treatment. — First and most important is rest, which 
in severe cases should be made as nearly absolute as 
possible. The patient must resist his constant desire to 
urinate and to empty the bowel, and must refrain from 
straining at stool or in urinating if he would avoid the 
dangers of prostatic abscess. Rest in bed with the hips 
elevated, the application of fomentations large enough to 
cover anus, perineum, and hypogastrium, hot sitz-baths 
or hot enemata given two or three times daily, the inter- 
nal administration of alkalies and bland fluids in quanti- 
ties sufficient to keep the urine unirritating (see hygiene 
of GonorrJiceci), and the use of anodynes to control pain 
and tenesmus, constitute the best treatment of most 
cases ; if begun early and faithfully continued, this 
treatment will usually render the attack a mild one. 

Anodynes are best given in the form of opium-and- 

1 belladonna suppositories, and in quantities sufficient to 
allay the irritation of the bladder and rectum and to 
keep the patient quiet. As in posterior urethritis, hyos- 
cyamus is often valuable in relieving tenesmus. Mus- 
tard or turpentine may be added to the fomentations to 
produce counter-irritation, and in severe cases ten or 
fifteen leeches may be applied to the perineum. 
The patient should be put on a light diet, and his 
I 



442 SYPHILIS AND THE VENEREAL DISEASES. 

bowels should be moved with enemata, cathartics being; 
generally contraindicated, though a brisk calomel purge 
at the beginning of treatment, or ylg- to \ grain of 
calomel given every hour until the bowels move, is often 
productive of excellent results. Sometimes it is neces- 
sary to give bromides and chloral to quiet the mental 
excitement, produce sleep, and allow the patient rest, 
but usually they are not as beneficial as the presence of 
a well-trained attendant who will properly execute the 
physician's orders, keep the patient under control, and 
add to his comfort and rest by daily sponging or skilful 
rubbing of the body, etc. All treatment of gonorrhoea 
should be suspended with the first symptoms of prosta- 
titis, and the prostate should not be teased by too 
frequent examinations through the rectum. Retention 
of urine should be relieved by the use of the hot bath 
when possible, but if this fails a small soft catheter may 
be used gently after first injecting the urethra full of 
warm oil. 

Finger and other German surgeons highly recommend 
the use of cold, instead of hot, local applications. If be- 
gun early enough, the course of the disease may be cut 
short by using the cold rectal sound. This instrument is 
a hollow sound with two longitudinal compartments con- 
nected at the end, through which water may flow in a 
constant stream. The sound is well oiled, is gently in- 
troduced into the rectum until it comes in contact wnth 
the prostate, and cold water — even ice cold — is allowed 
to flow through it for half an hour or an hour, once, twice, 
or three times a day. 

When an abscess forms the treatment is surgical, a peri- 
neal opening being always the most desirable. If fluctua- 
tion can be felt through the rectum, the abscess may be 



PROSTATITIS. 443 

aspirated or be punctured with a trocar, but an opening 
into the rectum is to be avoided when possible, since 
some of the contents of the intestine are certain to get 
into the cavity and to interfere with heaHng. When a 
small abscess bursts into the urethra, boric acid or salol 
and bland fluids internally, to keep the urine aseptic and 
unirritating, constitute the only treatment required unless 
further symptoms appear. Abscesses which open in other 
directions should be treated on surgical principles — with 
irrigations and astringent injections. 

II. Chronic Prostatitis. — Chronic prostatitis may 
follow an acute attack, may occur in subacute form dur- 
ing chronic urethritis or with stricture, or may arise from 
any cause that produces prolonged congestion or irrita- 
tion of the prostatic urethra. The inflammation may 
be limited to a few of the superficial follicles and glands 
opening into the urethra, and be very mild, simply 
catarrhal in type, or it may involve the entire glandu- 
lar structures, together with more or less, or even all, of 
the parenchyma of the prostate. 

Symptoms. — In the mild forms, commonly known as 
chronic follicidar prostatitis^ or prostatorrhoea, in which 
the superficial glands and follicles are alone affected, the 
chief symptom is the discharge from the meatus of a 
thick, sticky, bluish or milky-looking fluid composed of 
a mixture of thick, glairy mucus from the prostatic folli- 
cles, usually some pus, and more or less mucus from 
other portions of the urethra. This discharge is inter- 
mittent, appearing most frequently at the close of urina- 
tion, at stool, or after an erection, or it can be pressed 
out of the prostate by the finger in the rectum. The 
urine in the second glass is usually cloudy ; it may con- 
tain comma-like shreds even when that in the first glass is 



444 SYPHILIS AND THE VENEREAL DISEASES. 

clear, since the mucus, pus, and shreds are pressed out 
of the prostatic folHcles by the sphincter vesicae and the 
muscular fibres of the prostate in the act of expelling the 
last drops of urine. Under the microscope the discharge 
is seen to contain pus-cells, polygonal and cylindrical 
epithelium, amorphous and fatty matter, and the needle- 
shaped and whetstone-shaped " sperma-crystals." If, by 
pressure on the prostate, a drop of the prostatic secretion 
be obtained free from urine, and to it be added a drop of 
a I per cent, solution of ammonia phosphate, and the 
mixture be allowed to dry slowly under a cover-glass, 
these crystals can easily be demonstrated. Spermatozoa 
are not present unless the seminal vesicles are inflamed. 

The patient usually describes these discharges as semi- 
nal losses, and believes himself the subject of spermator- 
rhoea. In consequence he is often despondent and hy- 
pochondriacal and inclined to exaggerate greatly the 
severity of his subjective discomforts, which are usually 
confined to some vague and uneasy sensations in the 
perineum, with possibh' some increased frequency in 
urination and some irritability of the sexual organs. 

Extension of the inflammation to the deeper glands 
and parenchyma of the prostate produces a graver form 
of the disease, known as chronic parenchymatous prosta- 
titis. The symptoms of this form vary greatly, depend- 
ing upon the extent and severity of the process. In 
addition to the discharge, there may be tenesmus and 
increased frequency of urination, with pain and possibly 
slight hemorrhage at the close of the act. There are 
burning, heavy, uneasy sensations in the perineal region, 
with pains radiating to the urethra, testicles, groins, 
thighs, and back. These sensations are increased on 
urination, defecation, or sexual intercourse, and the pains 



) 



PR OS TA TITIS. 44 5 

may even be neuralgic in character, being often described 
as neuralgia of the urethra, testicle, and bladder. There 
are often teasing, tickling sensations of the prepuce and 
the meatus. In severe cases the pain is greatly increased 
by jolting, crossing the thighs, walking, or even by the 
sitting posture. 

The deep urethra and the vesical neck are often ex- 
ceedingly sensitive, and spasmodic contractions of the 
sphincter muscles may cause a sudden stopping of the 
stream near the close of urination. There is usually 
irritation of the sexual organs, with frequent emis- 
sions, which may be bloody ; in severe cases, though 
emissions and prolonged, often painful, erections are com- 
mon, sexual desire and gratification may be diminished or 
entirely absent. Spermatozoa are present in the semen, 
but, owing to the absence of normal prostatic secretions, 
they are inactive, and sterility results. 

The patient is usually mentally depressed, irritable, 
and melancholy. Other constitutional disturbances are 
slight at first, and may remain so for months, notwith- 
standing severe local symptoms and a hypochondriacal 
state of mind that is most deplorable ; but unless the 
local disorder is relieved and the mental condition is 
improved, there follows, sooner or later, a long series of 
morbid nervous phenomena constituting the unfortunate 
state generally known as " neurasthenia." These symp- 
toms are vague, varied, and numerous. At first they 
refer chiefly to the genito-urinary system, but later they 
may apply to any or every organ in the body. Among 
the earliest and most common complaints of these patients, 
besides those already given, may be mentioned constant 
weariness and weakness, aching pain in the back and 
legs, a heavy, dull feeling in the head, headache, loss 



446 SYPHILIS AND THE VENEREAL DISEASES. 

of memory and inability to concentrate the mind upon 
work, sleeplessness, hot and cold flushes or numbness 
with tingling sensations, and any or all of the symp- 
toms that may result from impaired functional activity 
of the various organs of the body. The patient may com- 
plain of many of these symptoms while still appearing 
well nourished, but in most cases that fail to improve, mal- 
nutrition, loss of weight, and impairment of the general 
health sooner or later result. The skill, patience, and tact 
of the physician are often taxed to the utmost in his efforts 
to determine if it be the local disease or the hypochon- 
driasis that is chiefly responsible for the neurasthenic 
symptoms. 

Dr. W. T. Belfield has called attention to the fact that 
chronic inflammation of the prostate is usually not 
limited to that organ, but invades portions or all of the 
seminal vesicle, vas deferens, and epididymis, together 
with the surrounding connective tissue ; he states that 
chronic suppuration is a frequent feature of such inflam- 
mation, the small abscesses being usually unrecognized 
until they rupture into the urethra, rectum, or pelvic 
tissues, or until revealed by autopsy. The extent and 
nature of this more diffuse inflammation may be respon- 
sible for some of the varied symptoms usually ascribed 
solely to chronic prostatitis. 

Treatment. — For the milder cases the use of the 
cold-steel sound, as recommended for chronic urethritis, 
is the most valuable remedy. Deep injections of nitrate 
of silver or lanolin ointments may be used in connection 
with the sound. Correct hygiene and the general health 
of the patient are of greatest importance, and sometimes 
the best results are obtained from a trip to the sea-shore 
or to the mountains combined with other measures 



PROSTA TI TIS. 447 

adapted to the needs of the individual. The mental 
state frequently calls for as much treatment as does the 
local condition, since it may be impossible to obtain rest 
and proper hygiene for the affected parts until the fears 
and anxieties of the patient have in some measure been 
removed. The cessation of local treatment to allow 
the organs a period of rest is often necessary ; and it 
must not be forgotten that too continuous or too ener- 
getic measures may aggravate the existing disorder and 
produce a severer type of the disease. Hot (iio° to 
120° F.) irrigation of the deep urethra is sometimes 
beneficial. 

In the more severe forms blistering the perineum is 
the most effective treatment. Mustard, turpentine, or 
cantharides may be used, but cantharidal collodion is 
perhaps the most convenient. The perineum is shaved, 
the scrotum and the margin of the anus are protected 
by a simple thick ointment, and the collodion is applied 
to one-half of the perineum. The scrotum is then pro- 
tected and kept out of the way by the use of a suspen- 
sory, and the perineum is covered with a light dressing 
of absorbent cotton. When the resulting blister has 
healed and the soreness diminishes, the other half of 
the perineum may be treated in the same way, and the 
process may be repeated often enough to keep one side 
or the other of the perineal surface constantly irritated 
for a number of weeks, until the symptoms of prostatitis 
have been largely relieved. During this treatment the 
patient must be kept quiet and in bed as much of the 
time as possible, while the state of his general health 
should be carefully studied and improved in every way 
possible. Tonics, mild laxatives or enemata, alkalies, 
and diluent drinks are necessary in most cases. 



448 SYPHILIS AXD THE VENEREAL DISEASES. 

Prognosis. — Recent cases recover under good man- 
agement ; older cases are less favorable, but with time, 
patience, hygiene, and good treatment they are greatly 
relieved and usually recover. The general health com- 
monly remains good unless disturbed by loss of rest 
and long-continued mental depression. Suppuration very 
rarely results fatally. 

VESICULITIS. 

Inflammation of the seminal vesicles may occur dur- 
ing or after the third week of gonorrhoea, as the result 
of a direct extension of the process from the posterior 
urethra. Acute vesiculitis, however, is less common 
than the chronic form, which may follow the former, but 
which more frequently appears in subacute form during 
chronic urethritis. It may also be due to stricture or 
to prolonged congestion, irritation, and inflammation of 
the posterior urethra from any cause. It is more com- 
mon in neurotic persons. Unrecognized acute or 
chronic vesiculitis is undoubtedly present in many cases 
of complicated urethritis. 

Symptoms. — In the acute form the symptoms are 
practically those found in acute posterior urethritis and 
acute prostatitis, with w^hich disorders vesiculitis is often 
associated. The differential diagnosis is frequently dif- 
ficult. In addition to tenesmus, frequent micturition, 
painful and disagreeable sensations in the perineum, etc., 
there are usually characteristic disturbances of the 
sexual functions. Sexual desire is stimulated and may 
be almost constant, and there are frequent emissions 
occurring on the slightest provocation, and prolonged, 
sometimes painful, erections. Ejaculation is usually 
precipitate, unaccompanied by pleasure or relief, and 



VESICUL ITIS. 449 

extremely painful. The seminal discharge contains pus, 
dead spermatozoa, and frequently blood. 

In subacute and chronic vesiculitis the above symp- 
toms may be present in lesser degree, or there may be 
great diminution of sexual desire, with, however, fre- 
quent and more or less painful emissions. The dis- 
charge contains less pus and blood and fewer sperma- 
tozoa, but is thicker and more gelatinous than normal, 
and, if obtained pure by expression with the finger, 
shows a tendency to coagulate. There are often neuras- 
thenic and other symptoms described in connection with 
chronic prostatitis. 

If the bladder be full and counter-pressure be made 
above the pubes, the finger in the rectum will reach, 
just above the prostate and to either side, a considerable 
portion of the seminal vesicle, which in acute cases is 
swollen, hot, throbbing, and sensitive, and in subacute 
cases is distended with abnormally thickened secretion 
and is tender on pressure. (The normal vesicle can 
rarely be recognized by the finger in the rectum.) 
The condition of the prostate should be determined 
before concluding the examination. Under favorable 
circumstances acute vesiculitis subsides in a week or 
less, and usually terminates in resolution ; but it may 
result in abscess or be followed by chronic inflam- 
mation. 

Treatment. — In acute vesiculitis the treatment is that 
of acute prostatitis — namely, absolute rest, hot applica- 
tions, anodynes, and general treatment of the patient. 
Much pressure upon the vesicle or frequent local inter- 
ference should be avoided, for fear of rupturing the vesicle 
or encouraging suppuration. If abscess forms, the treat- 
ment is surgical, as in prostatic and periprostatic abscess. 

29 



450 SYPHILIS AND THE VENEREAL DISEASES. 

In chronic vesiculitis hygiene and constitutional treat- 
ment have proven of greater service than local measures. 
Irrigation of the rectum with hot water may help in 
some cases. " Stripping " the vesicle, as recommended 
by Dr. Eugene Fuller,^ sometimes gives good results. 
The following is a brief outline of the method : The 
patient stands with his back to the operator, bends (at 
the hips only) forward, and rests his hands upon a chair. 
With one finger in the rectum and with the other hand 
making counter-pressure over the bladder, which should 
be full, the operator gently presses upon such portions 
of the distended vesicle as he can reach, and empties it 
of its contents. The secretion may appear at once at the 
meatus or be washed out later by the urine. The fre- 
quency with which the operation may be repeated varies 
greatly in different cases, but averages about once a 
week. Too frequent or rough manipulations aggravate 
the existing disorder and may result in acute vesiculitis. 

CYSTITIS. 
If, during gonorrhoea or gleet, the posterior urethra 
is involved, the inflammation may readily extend to the 
adjacent mucous membrane of the bladder. Such a 
cystitis, though it may include all the vesical membrane, 
is usually limited to the surface about the urethral orifice, 
the region commonly known as the neck of the bladder. 
It is probably due to simple extension of the inflamma- 
tion from the urethra or to pus-infection, and not to 
invasion of the membrane by gonococci, since cystitis 
accompanying gonorrhoea is usually much more amen- 
able to treatment than is the primary disease. It is 

^ Journal of Cutaneous and Genito-urinary Diseases, Sept., 1893, J^"^ 
and July, 1894. 



CYSTITIS. 451 

often classed as a mixed infection, though gonococci 
have never been demonstrated in the tissues of the 
bladder. The exciting causes of this form of cystitis 
are those of posterior urethritis, and they are found 
chiefly in such acts, surroundings, treatment, etc. as tend 
to congest or irritate the deep urethra or to convey pus 
from the urethra to the bladder. 

Symptoms. — The symptoms are essentially those 
of posterior urethritis. They may be very mild and 
scarcely noticeable, or so severe that there is a constant, 
almost irresistible, desire to urinate, with violent te- 
nesmus and the expulsion every few minutes of a few 
drops of urine mixed with pus and blood. Between 
these two extremes the symptoms may vary greatly. 

There is frequently a feeling of weight and discomfort 
in the perineum, with pains which radiate to the penis, 
testicles, groins, and back. The pubic and hypogastric 
regions are often tender and sensitive. In severe cases, 
in those of long duration, and especially in those com- 
plicated by the presence of stricture or enlarged prostate, 
there may be atony of the bladder-walls and partial 
retention of urine. If unrelieved, this condition is 
usually followed by ammoniacal decomposition of the 
urine, which then has a strongly fetid and ammoniacal 
odor, and contains a quantity of thick, viscid sediment 
that adheres to the bottom and sides of the vessel in 
which the urine is voided. Such urine is necessarily 
irritating to the mucous membrane of the bladder, and 
increases the severity of the inflammation. 

Constitutional symptoms are usually slight; but if 
large areas of the vesical mucous membrane be involved, 
there may be chills, fever, and other systemic disturb- 
ances. Such symptoms, however, appearing somewhat 



452 SYPHILIS AND THE VENEREAL DISEASES. 

suddenly during the course of cystitis, should always 
lead the physician to suspect the added presence of 
pyelitis. There is often more or less of the mental dis- 
tress common to inflammatory disorders of the genito- 
urinary tract. As in other complications of urethritis, 
the urethral discharge diminishes or disappears entirely 
during the course of the new disorder. Cystitis may 
vary in duration from a few days to several weeks or 
months, and may terminate in complete resolution or in 
some of the chronic forms of the disease. 

Diag-nosis. — The subjective symptoms in cystitis, 
prostatitis, and posterior urethritis are so much alike that 
they should never be relied upon for a diagnosis. Rectal 
examination will determine the presence or absence of 
prostatitis, and careful examinations of the urine should 
decide if the inflammation has extended from the pars 
posterior to the bladder, for gonorrhoeal cystitis with- 
out posterior urethritis rarely, if ever, exists. 

Thompson's two-glass method, as described in con- 
nection with Acute Posterior Urethritis, should be used, 
though it is often desirable to have the urine passed in 
three separate glasses. If the inflammation be limited to 
the posterior urethra, there will be times — when the urine 
has been retained in the bladder for but a few minutes, 
possibly half an hour or an hour — when the first portion 
of urine alone will contain pus, the other portions being 
clear. When this occurs, cystitis may be excluded. If 
the vesical neck be also involved, the first glass will con- 
tain most of the pus, but all the urine will be more or 
less clouded. If the cystitis be more extensive, the 
quantity of pus will be greater, and during the intervals 
of urination it will settle to the base of the bladder. In 
this case the amount of mucus and pus in the first glass 



CYSTITIS. 453 

depends on the activity of the inflammation in the pos- 
terior urethra and at the vesical neck ; the second glass 
contains the more or less clouded urine from the upper 
part of the bladder; while the urine in the third glass 
contains the mucus and pus that has collected at the 
base of the bladder, and is therefore more heavily clouded 
than that in either of the other two glasses. 

If in cystitis the urine be acid in reaction, as it may be 
in the early stages, and be allowed to stand in a glass for 
a {q\n minutes, two layers of precipitate will form. The 
first layer, that at the bottom, is composed chiefly of 
pus, is white, more or less dense, and crumbly in appear- 
ance. Above this is a looser, flocculent or cloudy layer 
of mucus and muco-pus. This upper layer forms more 
slowly, but soon settles sufficiently to leave a clear layer 
of urine at the top. In the more severe as well as in the 
older forms of cystitis the urine is usually neutral or 
alkaline in reaction. As the degree of alkalinity in- 
creases the pus and mucus form a thicker, glairy, stringy 
substance which adheres to the membrane of the bladder 
and to the vessel in which it is placed. It cannot be 
dropped from one test-tube to another, but goes over in 
stringy masses. This appearance is most marked in 
ammoniacal decomposition of the urine, which then not 
only has a foul odor and contains pus, but also shows 
under the microscope large numbers of micro-organisms, 
amorphous phosphates, and coffin-lid, triple-phosphate 
crystals. This condition of the urine is not found unless 
cystitis is present. 

During the course of cystitis, pyelitis may occur 
without additional symptoms, so that in every case in 
which the urine constantly contains pus the possible 
presence of pyelitis should be considered. 



454 SYPHILIS AND THE VENEREAL DISEASES. 

Treatment. — The details of treatment are practically 
those of acute prostatitis. The chief indications are met 
by rest in bed, large dilution of the urine with bland 
drinks, hot local applications and hot baths, and ano- 
dynes to reliev^e pain and tenesmus. It is not desirable 
to render the urine alkaline, as that would favor ammo- 
niacal decomposition. Balsam of copaiba — less frequently 
oil of sandalwood — is often highly efficacious in reducing 
the acute symptoms. Boric acid or salol in doses of 5 
or 10 grains every three or four hours is valuable in ster- 
ilizing the urine and preventing decomposition. Citrate 
or acetate of potash in 10- to 20-grain doses three or 
four times a day is sometimes of service as a diuretic. 

If the inflammation continues and becomes chronic, 
the treatment is that of chronic or catarrhal cystitis from 
other causes. 

PYELITIS. 

Inflammation of the pelvis and calices of the kidney 
occasionally follows gonorrhoeal cystitis. Its occurrence 
is favored by the presence of stricture, enlarged prostate, 
or any interference with the free outward flow of urine. 
Cachexia, bad hygiene, and alcoholic excesses may also 
favor its development. 

Symptoms. — This complication may develop in- 
sidiously, and until severe enough to affect the general 
health it may present no symptoms in addition to those 
of cystitis. In the majority of cases, however, there is 
pain, of a dull, burning character, in the back and the 
loins, extending possibly to the bladder, testicles, peri- 
neum, and thighs. The pain is increased by pressure 
over the kidneys or by active exercise. There is usually 
some fever accompanied by chills, that may recur with 
a regularity suggesting malaria. 



PYELITIS. 455 

Diagnosis. — The sudden appearance, during cystitis, 
of constitutional disturbances should suggest pyelitis. 
Other symptoms are of value, but the diagnosis rests 
chiefly upon examinations of the urine. In pyelitis the 
urine is decidedly acid unless modified after reaching the 
bladder. The pus is intimately mixed with the urine, 
and on standing settles to the bottom in a greenish, com- 
pact, creamy or oily-looking layer. If decomposition 
in the bladder is prevented, the urine is not only acid, 
but on standing remains so for several days, and bacteria 
do not readily develop in it, as they do in urine from 
cystitis. 

Albumin is present in larger amount than would be 
furnished by the pus alone. Under the microscope the 
urine shows, besides pus and mucus, cylindrical masses 
of pus-cells, occasional hyaline or granular casts, some 
red blood-corpuscles, and epithelial cells that in some 
cases may be recognized as peculiar to the kidney. 
Later in the disease there are sudden changes from 
day to day in the amount of pus present in the urine. 
Finally, in doubtful cases the bladder may be washed 
out thoroughly and the urine allowed to collect for fifteen 
or twenty minutes, when it is drawn from the bladder 
with a catheter; if pus is evenly mixed with the urine, it 
undoubtedly comes from the kidney. 

Treatment. — The treatment of cystitis should be con- 
tinued in the form of rest in bed, diluent drinks, diuretics, 
anodynes, and the avoidance of all stimulating articles 
of food and drink. Hot baths, with hot fomentations or 
cupping over the region of the kidney, often aid in reliev- 
ing pain. Copaiba, boric acid, or salol can often be used 
to advantage. Under such treatment, and with the re- 
moval of the cause, this form of pyelitis usually termi- 



45 6 SYPHILIS AND THE VENEREAL DISEASES. 

nates in prompt recovery, though it may progress to 
graver stages of the disease or may become chronic. 

FOLLICULITIS. 

In most cases of gonorrhoea inflammation extends to 
some of the folHcles and glands opening into the urethra. 
This comphcation may occur in any part of the canal, but 
is most frequent in the fossa navicularis, bulb, or pros- 
tatic portion, where the glands are large and numerous 
If the inflammation is mild in type, the follicle becomes 
slightly swollen and tender and discharges pus into the 
urethra. This condition may be present in a number of 
glands during an acute gonorrhoea without adding ap- 
preciably to the urethral symptoms, and therefore without 
being recognized, but it can easily be demonstrated 
when the follicles at the orifice of the urethra are in- 
volved. The lips of the meatus are then red and swollen ; 
if their surfaces be cleansed and slight pressure be made 
upon them, pus will be seen escaping from the narrow 
openings of the follicles. 

If the inflammation is more severe, the duct may be- 
come occluded by the swelling of the mucous mem- 
brane, and the follicle or gland becomes a cyst filled 
with pus. At first no larger than a pin-head, and 
slightly, if at all, painful, it may remain stationary for 
some time as a small firm nodule ; or it may grow 
slowly, remain inactive for months or years, and finally 
be absorbed ; or it may increase more rapidly, become 
sensitive, soften, and discharge externally, leaving a fis- 
tula which may persist indefinitely. When, as occasion- 
ally happens, one of these cysts opens into the urethra, 
it may discharge its contents and refill repeatedly, or 
may become irritated by the urine and result in peri- 



PERIURE THRiriS. 457 

folliculitis. Folliculitis may persist in subacute form 
and furnish a urethral discharge long after the rest of 
the urethral membrane has recovered. 

Treatment. — If the inflammatory symptoms are acute, 
rest and hot applications should be employed. When 
fluctuation is detected, an incision should be made, to 
allow the escape of the pus externally and to prevent an 
opening into the urethra. Later the cyst may be enucle- 
ated entirely or the sac may be injected with a drop of 
pure carbolic acid or a strong solution of nitrate of silver. 
When a cyst opens into the urethra, the cautious use of 
the full-sized steel sound is of service in keeping the sac 
empty. In indolent cases absorption may be promoted 
by the external use of oleate of mercury in strength vary- 
ing from 2 to 10 per cent. 

PERIURETHRITIS. 

As an unusual result of folliculitis the inflammation 
extends beyond the limits of the follicle or gland and 
invades the surrounding cellular tissue. The process 
may then terminate in a circumscribed abscess or, very 
rarely, in the suppuration and destruction of large por- 
tions of the spongy and cavernous bodies of the penis. 
The commonest sites of periurethritis are in the fossa 
navicularis, where the abscess generally forms on one 
side of the fraenum, and in the bulb, where it usually 
develops in the central line. Beginning in the bulb, the 
inflammation may involve the root of the penis and the 
scrotum, or rarely the entire perineum and the tissues 
about the anus. The abscess usually opens externally, 
but it may discharge into the urethra, and may result in 
urinary fistula or in infiltration of urine through large 
portions of the surrounding tissues, causing suppuration 



458 SYPHILIS AND THE VENEREAL DISEASES. 

and destruction of these parts. The conditions favorable 
to infiltration and abscess-formation are found just back 
of a stricture, where the urethral walls are damaged and 
weakened. The abscesses are more or less painful, and 
may interfere by pressure upon the urethra with the 
passage of urine. When suppuration is extensive the 
constitutional symptoms may be marked. The cica- 
trices which are left after healing of such abscesses may 
be slight, or so extensive and deforming that an erection 
of the penis is attended by crooking or bending of the 
organ, and possibly by pain. 

Treatment. — Absolute rest of the genital organs, and, 
when possible, of the entire body, is of the greatest im- 
portance. To this end a light diet, gentle evacuation 
of the bowel, absence of all sexual excitement, and 
horizontal position of the body are necessary. If the 
inflammation be recognized early, it may be aborted 
by cold compresses and inunctions of the oleate of mer- 
cury. If suppuration begin, boric-acid fomentations 
should be constantly applied, and an early, often a deep, 
incision is necessary to evacuate the pus and to prevent 
an opening into the urethra. It is neither wise nor safe 
to wait for fluctuation before using the knife. If there 
are other evidences of suppuration, or if the inflammation 
has been in progress for a week, it is better to make a 
free incision than to run the risk of allowing the abscess 
to open into the urethra. This is especially true of an 
abscess situated in the bulb, where an internal opening is 
liable to be followed' by extensive infiltration of urine and 
by perineal abscess. After discharging, the cavity should 
be cleaned daily and packed loosely with iodoform gauze 
until healthy granulations are obtained. All manipula- 
tions should be gently and carefully performed, lest 



cowPERiris. 459 

communication between the gland and the urethra be re- 
estabhshed and a urinary fistula be formed. 

When an abscess ruptures into the urethra, the treat- 
ment consists in rest, fomentations, and a position that 
will favor drainage. The case must be watched carefully, 
and as soon as local swelling, pain, interference with uri- 
nation, or fever indicates extravasation of urine and fur- 
ther suppuration, an external opening should at once be 
made. The further treatment is that of urinary fistula. 

Resolution may be incomplete, leaving a small, indo- 
lent nodule which persists for months. Such a condi- 
tion will usually disappear under inunctions of oleate of 
mercury. 

COWPERITIS. 

Inflammation of Cowper's glands is a rare complication 
of gonorrhoea. It may occur after the second week, but 
it usually begins between the third and fourth weeks. 
The patient complains of a sticking pain, of tension, or 
of tenderness in the perineum on pressure (as in sitting). 
On examination a deep-seated, round or oval, tender 
nodule, about the size of a bean, is discovered midway 
between the anus and the posterior border of the scrotum 
and at one side of the raphe. It is sometimes pear-shaped, 
in which case the larger end is toward the anus. The 
tumor usually grows rapidly in size, and by pressure 
upon the urethra may interfere with micturition. The 
surrounding tissue becomes involved, so that the tumor 
loses its sharp outline, becomes doughy or boggy to the 
touch, and may extend somewhat beyond the median 
line. Suppuration is attended by local throbbing pain 
and by chills and fever. Many mild cases undergo reso- 
lution, but a large abscess may form and may open ex- 



460 SYPHILIS AXD THE VENEREAL DISEASES. 

ternally or internally. In the latter case there is great 
danger of infiltration of urine and deep perineal abscess. 
Treatment. — The treatment is that of periurethral 
inflammation and abscess. 

LYMPHANGITIS. 

In severe cases of gonorrhoea more or less lymphangi- 
tis is common. In its simplest and mildest form there 
are no subjective sensations, but one or more lymphatics, 
usually on the dorsum of the penis, can be felt beneath 
the skin as small indurated cords. Occasionally such a 
cord may be traced to the groin. If the inflammation 
runs a little higher, perilymphangitis results and is mani- 
fested by reddish streaks along the course of the lym- 
phatics, which may be knotted and tender. There may 
be a more diffuse redness of the skin, which is then oedem- 
atous, swollen, hot, and sensitive. The inguinal glands 
ma}- become swollen, tense, and painful. 

Treatment. — Rest, elevation of the penis, and boric- 
acid fomentations are usually all the treatment necessar}'. 
As a rule, the inflammation terminates in resolution. If 
pus forms, it should be evacuated early to prevent bur- 
rowing in the loose tissues, as a considerable portion, or 
even all, of the skin and the subcutaneous tissue of the 
penis could be thus destroyed. 

ADENITIS. 

During a severe case of gonorrhoea it is not uncom- 
mon for one or more of the inguinal glands to become 
slightly swollen and tender; but suppuration is quite 
unusual, and when it does occur the abscess heals 
kindly after discharging the pus, which is not auto- 
inoculable. 



GONORRHCEAL RHEUMATISM. 46 1 

Treatment for the adenitis, aside from that given for 
the gonorrhoea, is usually unnecessary. When the 
gland first begins to swell and become sensitive, it may 
be well to paint the overlying skin with tincture of 
iodine or to apply a 2 per cent, oleate of mercury. If 
pain and swelling become pronounced, rest, hygiene, 
and boric-acid fomentations give relief If pus forms, 
the abscess should be opened and treated on surgical 
principles. Scraping is rarely necessary, since the 
cavity usually heals kindly and rapidly under daily 
cleansing and packing with iodoform gauze. 



GONORRHCEAL RHEUMATISM. 

In certain individuals gonorrhoeal infection is always 
attended by a complication known as " gonorrhoeal 
rheumatism." These individuals are not, as a rule, 
subject to other forms of rheumatism. 

Etiology. — Various theories are offered to explain 
the cause of this disease and its relation to gonorrhoeal 
infection, but none of them have yet been proven. In 
some cases there seems to be no doubt that the gono- 
cocci are carried through the blood to the joints, for, 
although these micro-organisms have not been dis- 
covered in the blood, they have been found in the fluids 
in the affected joints, and their identity has been fairly 
well established through their behavior with stains and 
through culture-experiments. Successful inoculations 
from these cultures are, however, wanting. In other 
cases the joint disease seems to be essentially pyaemic, 
and to be due to infection with the pus coccus, which 
gains admittance to the circulation through the urethral 
or other epithelium that has been damaged or destroyed 



462 SYPHILIS AND THE VENEREAL DISEASES. 

by the gonococci. It is believed that some cases are 
due to ptomaine-poisoning. 

The disease does not occur with non-infectious ure- 
thritis, but it has resulted from gonorrhoeal infection 
of the conjunctiva or vagina, and therefore cannot be 
due simply to urethral irritation. It occurs in about 
2 per cent, of all cases of gonorrhoea, and it is much 
more frequent in men than in women. A rheumatic 
diathesis and the usual causes of the commoner ar- 
ticular rheumatism have no apparent influence in the 
production of gonorrhoeal rheumatism ; while an indi- 
vidual who has once had this complication of gonor- 
rhoea rarely escapes in future infections, even when 
every precaution is taken to prevent its occurrence. 

Symptoms. — The period at which the disease appears 
varies, but in about three-fourths of all cases it occurs 
during the third or fourth week of gonorrhoea. It may 
be m.uch later, and has been reported as early as the 
fifth day. It does not have the effect — as do most of 
the complications of gonorrhoea — of diminishing the 
urethral discharge ; on the contrary, changes in 
the degree and intensity of the urethral inflammation 
are usually promptly followed by similar changes in the 
rheumatic symptoms. 

In about 40 per cent, of all cases the disease is 
limited to a single joint, and when polyarticular it is 
usually confined to two or three joints, which it attacks 
in succession, and not simultaneously. Finger collected 
statistics showing the joints affected in 376 cases as 
follows: Knee, 136; tibio-tarsal, 59; wrist, 43; finger, 
35; elbow, 25; shoulder, 24; hip, 18; maxillary, 14; 
metatarsus, 7; sacro-iliac, 4; sterno-clavicular, 4; chon- 
dro-costal, 2 ; intervertebral, 2 ; crico-arytenoid, 2 ; 



GONORRHCEAL RHEUMATISM. 463 

peroneo-tibial, i. Besides the joints, synovial bursae 
and the synovial sheaths of tendons and muscles may 
be involved. 

All attempts to classify the widely varying symptoms 
of gonorrhoeal rheumatism in distinct types have proven 
unsatisfactory. The classification here followed is sub- 
stantially that given by Finger : 

I. Acute Monarticular Gonorrhoeal Rheumatism. — This 
is the most frequent form of the disease, and usually 
appears in one of the large joints, most commonly the 
knee. The local disorder may be preceded by slight 
constitutional disturbance and by tenderness of several 
articulations, or the first symptoms may be pain and 
swelling of the affected joint. The tumefaction usually 
increases rapidly, with sufficient exudation to produce 
considerable tension. Pain is usually moderate, but 
may be mild or violent. Fluctuation is always distinct. 
Fever — which may be as high as 103° F. — and other 
systemic disturbances are present for a few days, but 
they rapidly subside. The swelling and the exudate 
remain and interfere with motion of the joint. 

The exudate may be wholly absorbed in the course 
of a few weeks, complete recovery following, or there 
may be a relapse of the acute symptoms — usually fol- 
lowing exacerbations of the urethritis — which greatly 
increases the natural tendency of the disease to become 
chronic and to terminate in hydrarthrosis. In rare in- 
stances the disease terminates in suppuration, which is 
announced by its usual symptoms — namely, chills and 
fever, an increase of the local swelling, pain which 
becomes throbbing in character, and an intense redness 
of the skin covering the parts. The pus bursts through 
the capsule and burrows between the tendons and mus- 



464 SYPHILIS AND THE VENEREAL DISEASES. 

cles to the surface. The usual result of this process is 
pyaemia and death. Recovery with ankylosis is pos- 
sible. 

2. Acute Polyarticular Gonorrhoeal RhemnatisDi. — The 
symptoms are those of the preceding variety, except 
that the disease involves two or more joints and that the 
constitutional disturbances are usually more pronounced. 
The latter may be acute and severe for a few days, but 
they do not last long. They may, however, recur a 
number of times as new joints are affected or following 
exacerbations of the urethritis. The fever does not 
often go above 103° F. The pericardium and the endo- 
cardium are rarely implicated. The mild character and 
the brief duration of all the general symptoms, as com- 
pared with the severity of the local disorder, form a 
striking feature of the disease. 

The affection may be limited to two — often symmetri- 
cal — ^joints, or it may pass in succession to three or 
four : the implication of a larger number of joints is ex- 
ceptional. Simultaneous invasion of two or more joints 
is unusual, and the disease does not travel rapidly from 
one joint to another, nor does the involvement of a 
second joint hasten recovery in the first. Absorption of 
the effusion is slow, and, as in the monarticular variety, 
the disease may terminate in recovery, in chronic 
hydrarthrosis, or in pyaemia. 

This variety of the disorder resembles more than do 
the others simple inflammatory rheumatism. 

3. Subacute Polyarticular Gonorrhoeal Rheumatism. — 
This form of the malady is identical with the preceding, 
except that the fever is never higher than 101° F. and 
that the subjective symptoms are very slight. It is 
evident that a sharp dividing-line cannot be drawn 



GONORRHCEAL RHEUMATISM. 465 

between the two forms. Finger considers this variety 
of the disease second in order of frequency. 

4. Chronic Gonorrhceal Rheumatism ; Hydrartlirosis. — 
This is a common form of the disease, is usually mon- 
articular, and is commonly found in the knee, the ankle, 
or the elbow. It may follow the acute or the subacute 
form, or it may appear independently. In the latter case 
it often develops insidiously, and it may not be noticed 
by the patient until the effusion is sufficient to interfere 
with motion ; or the effusion may take place rapidly, 
and may be accompanied by some pain which is in- 
creased on walking or on other movements of the joint. 
Fluctuation may be the sole evidence of the disease. If 
the effusion be considerable, motion in the joint is more 
or less limited ; if the exudate be excessive, there may 
be abnormal mobility of the joint, due, undoubtedly, to 
loosening of the ligaments. Absorption is occasionally 
rapid, but usually it is very slow and the fluid may be 
many months in disappearing. Adhesions and other 
deformities may leave an impaired joint. 

Fournier's classification recognizes a form of gonor- 
rhceal rheumatism in which neither structural nor func- 
tional evidences of disease are observed, and which may 
present no symptoms other than vague, wandering or 
persistent pains in some of the larger joints. These 
pains are very similar to those sometimes found in the 
early stages of syphilis, and they are often very rebel- 
lious to treatment. 

The synovial sheaths of tendons connected with the 
affected joints may be involved, and, occasionally they 
are affected independently of the joints. There is red- 
ness of the skin, with a doughy, painful swelling that 
may extend some distance along the tendon. Motion of 

30 



466 SYPHILIS AND THE VENEREAL DISEASES. 

the muscle is prevented by the pain, which may persist 
after the swelling disappears. The bursa in front of the 
tendo Achillis and that beneath the inferior tuberosity 
of the OS calcis are frequently involved. Other bursae 
are occasionally implicated. Rheumatic symptoms are 
sometimes present in the muscles, more especially in 
those connected with the affected joints. 

Ophthalmic symptoms are not infrequently present. 
They are most common in connection with the poly- 
articular form of rheumatism. In rare instances they 
appear without rheumatic symptoms in other parts of 
the body. The parts of the eye that may be affected 
are the iris, the membrane of Descemet, and the con- 
junctiva. The iritis presents symptoms similar to those 
occurring when the affection results from other causes : 
the conjunctiva is reddened; the subconjunctival capil- 
laries are injected, and can be seen radiating outward 
from the margin of the cornea : the iris is clouded and 
discolored, and its movements are sluggish ; vision is 
somewhat impaired ; posterior synechiae may form ; pain 
may be severe or absent, but there is usually photopho- 
bia and lachrymation. 

In inflammation of the membrane of Descemet (aquo- 
capsulitis, serous iritis) the symptoms are less acute. 
The fluid in the anterior chamber is clouded by the 
presence of a plastic exudate and epithelial cells from 
the iris ; vision is thus impaired. Flocculi may be 
deposited on the membrane of Descemet, giving this 
part of the cornea a punctate appearance. The iris may 
be slow in its movements, and exceptionally synechiae 
may form, but other symptoms of iritis are ^wanting. 
This is the commonest form of ophthalmia associated 
with gonorrhoeal rheumatism. 



GONORRHCEAL RHEUMATISM. 467 

The conjunctival form of gonorrhceal rheumatic oph- 
thalmia, described by Fournier, is very rare, and is 
simply a mild form of conjunctivitis having a scanty, 
muco-purulent discharge. The prognosis is entirely 
favorable. This form of conjunctivitis must not be con- 
fused with the infectious gonorrhceal form (see table of 
diagnosis in Gonorrhceal Ophthalmia). 

These forms of ophthalmia usually follow the course 
of the gonorrhoea on which they are dependent. As a 
rule, they affect both eyes, but not at the same time. 
The prognosis is favorable, and the only results to be 
feared are the adhesions which may follow iritis, or,' 
rarely, inflammation of the membrane of Descemet. 

Among the occasional and unusual complications of 
gonorrhceal rheumatism are pericarditis and endocar- 
ditis. Neuralgia of the sciatic and other nerves has 
been reported, as well as indefinite spinal symptoms 
consisting of disturbances of sensory and motor func- 
tions of the nerves. Purpura, erythema multiforme, and 
other eruptions on the skin may occur in connection 
with the disease, but in most cases the eruption is prob- 
ably due to some drug given to relieve the rheumatism. 

Pathology. — Regarding the pathology of the disease 
little is known. Post-mortem examinations have been 
made on a few fatal pyaemic cases. In some of these 
cases there were erosions of the cartilages and bones, 
and even complete destruction of the cartilages, with 
dissection of the periosteum from several inches of the 
femur. Gonococci were found in some instances. In 
more favorable cases puncture or incision of the joint 
has disclosed a serous, sero-fibrinous, or sero-purulent 
fluid, which in the majority of cases contained cocci 
that were apparently identical with gonococci. 



468 SYPHILIS AND THE VENEREAL DISEASES. 

Diagnosis. — When the disease comphcates successive 
gonorrhoeal infections, or when it is limited to a single 
joint, the diagnosis is usually made without difficulty. 
The following is a table of differential diagnosis as given 
by Fournier, with some modifications : 



Gonorrhccal Rheumatistn. 

Cause. — Gonorrhoeal infection. 

Cold and rheumatic diathesis 

without influence. 
Rare in women. 

Fever and systemic symptoms usual- 
ly mild and often absent. Acute 
.symptoms, when present, are of 
brief duration. 

Often limited to one joint, never 
involves many. 

When polyarticular, the joints are 

affected consecutively, and not 

simultaneously. 
Moves from one joint to another 

less quickly. No delitescence ; 

no real jumping from one joint to 

another. 
Local pain less intense and shorter 

in duration. More relief from 

rest and position. Pain often 

slight or even absent. 
Secondary hydrarthrosis common. 
No sweating. 

Urine not modified. 

Blood does not furnish marked 
bufify-coat. 

Cardiac complications very excep- 
tional. 



Simple Rheumatism. 

No relation to gonorrhoea. Habit- 
ual causes are cold, inheritance, 
rheumatic diathesis, etc. 

Common in the female, though less 
frequent than in the male. 

Fever and other systemic symptoms 
are almost always present and 
are much more severe and more 
prolonged. 

Rarely limited to less than two or 
three joints ; may involve nearly 
all. 

Simultaneous involvement of several 
joints is the rule. 

Movable, ambulatory fluxions ; 
rapid delitescence, jumping from 
one joint to another. 

Pains are usually intense, some- 
times excessive, last much longer, 
and are but partially relieved by 
rest and position. 

Secondary hydrarthrosis rare. 

Abundant sweats, usually acid, are 
characteristic. 

Urine specially modified. 

Blood forms a firm, concave clot 
with buffy-coat. 

Cardiac complications frequent. 



CONOR RHCEAL RHEUMATISM. 46g 

Gono7-rh(eal Rhemnatisvi. Simple RJieuinatis7n. 

Frequently complicated by a special Eye not affected ; the bursse escape, 

ophthalmia, synovitis of tendon- as do usually the sheaths of the 

sheaths, bursoe, etc. The latter tendons, 
localities may be exclusively im- 
plicated. 

Relapses are frequent, and are Relapses frequent, but independent 

usually dependent on exacerba- of state of urethra. Can often 

tion of urethritis. Recurs al- be traced to exposure to cold, 

most invariably with succeeding vi^eather-changes, etc. 
gonorrhoeal infections. 



Treatment. — No satisfactory treatment of gonorrhoeal 
rheumatism has yet been found. In the acute and sub- 
acute stages sahcylate of sodium, salol, and occasionally 
phenacetin, are of some value. Taylor recommends oil 
of gaultheria in capsules each of from lo to 20 minims 
three or four times a day. Rest, a light diet, tonics, and 
hygienic measures are always indicated. The urine 
should be kept unirritating by the use of bland drinks 
and, when necessary, alkalies. Copaiba, sandalwood, 
and cubebs are of decided benefit when they lessen the 
urethral inflammation, since changes for the better or the 
worse in the rheumatic symptoms usually closely follow 
similar changes in the urethritis. For this reason local 
treatment of the urethra and all possible sources of 
urethral irritation should carefully be avoided. 

The most satisfactory results usually come from local 
treatment of the joint. During the acute stages absolute 
rest, with the constant application of fomentations or 
poultices as hot as can be tolerated, will usually give 
prompt relief In unusual cases, when the pain is exces- 
sive, tobacco or opium and belladonna may be added to 
the fomentations. Blistering of the surface and frequent 
applications of the Paquelin cautery are excellent 



470 SYPHILIS AND THE VENEREAL DISEASES. 

methods in both acute and subacute cases. To promote 
absorption in subacute and chronic cases, the surface 
over the joint may be painted with iodine or rubbed with 
oleate of mercury in lanoHn (2 to 10 per cent.); or mas- 
sage, friction, and electricity may be found of benefit. 
All forms of local treatment should be supplemented by 
firm, even pressure secured by a properly applied roller 
or elastic bandage or by an elastic cap or splint made 
to fit the joint. In chronic and persistent cases it may 
be necessary to immobilize the joint in a plaster cast. 
Aspiration of the joint followed by irrigation with a 2 
per cent, solution of carbolic acid may prove effective 
when other measures fail. In the rare cases in which 
suppuration occurs the treatment is entirely surgical. 

The ophthalmic symptoms call for little special treat- 
ment. In iritis a solution of atropine (gr. ij to Ij) should 
be used to keep the pupil dilated and to prevent adhesions. 
All other treatment is chiefly symptomatic. A light diet, 
rest, correct hygiene, and proper treatment of the ure- 
thritis are always in order. 

Prognosis. — With thorough and persistent treatment 
most cases recover. Fatal cases are few, but the disease 
has a decided tendency to continue as a chronic hydrar- 
throsis. The prognosis should therefore be guarded. 

GONORRHCBAL CONJUNCTIVITIS. 

Synonyms. — Gonorrhoeal ophthalmia ; Blennorrhagic 
ophthalmia; Purulent ophthalmia; Blennorrhagic con- 
junctivitis; Purulent conjunctivitis. 

In the adult gonorrhoeal conjunctivitis is fortunately 
rare, but when it does occur it is an exceedingly grave 
disease, since it usually results in impairment or destruc- 
tion of vision in the affected eye. 



GONORRHCEAL CONJUNCTIVITIS. 47 I 

Etiology. — Direct infection of the conjunctival mem- 
brane with pus containing gonococci is apparently the 
sole cause. The smallest particle, however, of such pus, 
even after it has been dried for some days, is sufficient to 
cause infection. Successful inoculation of the urethra 
has been accomplished with gonorrhceal pus diluted to 
one part in a thousand. These statements apply only to 
gonorrhoeal conjunctivitis, and not to other, usually 
milder, forms of purulent conjunctivitis. In most cases 
the disease of the conjunctiva is found in individuals suf- 
fering from gonorrhoea, and who have conveyed some of 
the discharge from the genitals to the eye ; but pus from 
any form of gonorrhoeal inflammation may be carried by 
means of fingers, handkerchiefs, towels, etc., and produce 
the disease in any eye with which they come in contact. 
In this way the eyes of the physician, nurse, or companion 
are occasionally infected. 

Symptoms. — The period of incubation, or the time 
which elapses between the infection and the first apparent 
symptoms, varies from a few hours to two or three days. 
Usually the duration of this period cannot be determined, 
since the infection is rarely recognized at the time of its 
occurrence. 

The symptoms begin as a mild conjunctivitis, with 
lachrymation and itching, burning, or irritation of the 
conjunctiva, which is more or less reddened and injected. 
These symptoms, however, rapidly increase in severity; 
the discharge often becomes purulent in a few hours, and 
the inflammation reaches its greatest intensity on the 
second or third day. The lids are then oedematous and 
swollen, usually hard and tense, with a dusky-red, glisten- 
ing surface, and to the touch are hot and painful. The 
upper lid often overhangs the low^er, and the patient is 



4/2 SYPHILIS AND THE VENEREAL DISEASES. 

usually unable to open the eye. The discharge is thin, 
creamy, and abundant, and escapes between the edges of 
the lids, flowing over the cheek, where it may dry in 
crusts and excoriate the skin ; later it is thicker and less 
abundant. 

On carefully separating the lids a quantity of the 
retained discharge will escape, and the conjunctiva is 
seen to be intensely red, swollen, rough and spongy, 
and often dotted with hemorrhagic points. As the lids 
are opened the pent-up secretion sometimes escapes in 
quite a jet, and the examiner should be very careful to 
keep his own eyes at a safe distance. The swollen 
and congested ocular conjunctiva is lifted up from 
the globe by the exudate, overlaps the margin of the 
cornea, and forms a circular wall around it. The cornea 
thus forms the bottom of a depression filled with pus, 
and cannot be seen until the latter is removed. A plastic 
exudate may cov^er portions of the conjunctiva, the re- 
moval of which exudate is followed by hemorrhage. 

Pain in the eye and in the orbital region is often 
intense. The local temperature is increased, but general 
fever is mild or absent. Systemic disturbances are usu- 
ally limited to those caused by the pain, anxiety, and 
mental distress. 

The great danger lies in extension of the inflamma- 
tion to the cornea — a process that is encouraged by the 
irritating effects of the pus retained in contact with the 
surface of the cornea, and by the interference in the 
corneal circulation resulting from the pressure produced 
by the chemosis and the tensely swollen, heavy lids. 
Cloudiness of the cornea may be present ; this cloudi- 
ness may disappear under treatment, leaving no perma- 
nent defects. Ulceration of the cornea, however, is to be 



GONORRHCEAL CONJUNCTIVITIS. 473 

dreaded ; it begins as superficial losses of tissue, usually 
near the margin, but it may first appear at the centre. 
Such ulceration may progress rapidly and destroy large 
portions or all of the cornea, resulting in staphyloma, 
prolapse of the iris, escape of the entire contents of the 
eye, or even purulent panophthalmitis. In less severe 
cases the ulceration may be arrested by prompt treat- 
ment, and the vision may be but partially lost. The 
duration of the disease is from four to twelve weeks. 
In favorable cases, with no involvement of the cornea, 
complete recovery occurs in five or six weeks, or there 
is left a chronic conjunctivitis which disappears under 
appropriate treatment. 

Pathology. — There is inflammation of the conjunc- 
tiva and of the subconjunctival tissues. The point of 
special interest is the presence and location in the tissues 
of the gonococci : they rapidly penetrate to the upper 
layers of the subepithelial tissues, where their presence 
is soon followed by the phenomena of inflammation. 
Just where they chiefl}^ proliferate is an undecided ques- 
tion, but they are most numerous in the epithelium and 
in the secretion. 

Diagnosis. — The symptoms are usually so pronounced 
that the diagnosis is not difficult. Purulent conjuncti- 
vitis from other causes presents symptoms of the same 
type, but less severe, and the secretion does not contain 
gonococci. Treatment is the same. To avoid confusing 
the two distinct types of ophthalmic disease that may 
complicate gonorrhoea, the following table of Fournier's 
is given : 



474 SYPHILIS AND THE VENEREAL DISEASES. 



Gonorrhceal Conjunctivitis. 

Essential cause is inoculation of the 
conjunctiva with gonorrhoeal pus. 

A rare affection. 



May affect subjects not suffering 
from gonorrhoea. 

Usually but one eye involved. 

The symptoms are those of the 
gravest forms of purulent con- 
junctivitis ; they affect the con- 
junctiva primarily. 

Symptoms fixed, not going from 
one eye to the other. 

No tendency to relapse in subse- 
quent gonorrhoeas. 

No coincidence with rheumatic 
manifestations. 

Prognosis excessively grave ; often 
loss of eye. 

Eye is saved only by most ener- 
getic treatment. 

Gonococci in the discharge. 



Gonorrhceal {Rheumatic) 
Ophthalmia. 

Not contagious ; develops under 
the influence of an internal cause, 
the nature of which is unknown. 

An infrequent complication of gon- 
oiThoea. More common than gon- 
orrhoea! conjunctivitis — 14: I. 

Only attacks patients already suffer- 
ing from gonorrhoea. 

Commonly both eyes. 

Symptoms are those of inflamma- 
tion of the membrane of Desce- 
met, of an iritis, or of a mild 
conjunctivitis. 

Symptoms may be mobile, passing 
from one eye to the other. 

Frequent relapses in the course of 
subsequent gonorrhoeas. 

Occurs with gonorrhoeal rheuma- 
tism, rarely without. 

Prognosis without gravity. 

Expectation, or the simplest treat- 
ment, sufficient for a cure. 
No gonococci. 



Treatment. — The treatment must be prompt and 
thorough. A few hours' delay may cause the loss of 
the eye. The patient should go to bed in a darkened 
room, and should have a trained nurse in constant at- 
tendance, to keep the surfaces cleansed and properly 
dressed and to protect the sound eye from infection. In 
some cases it is best to protect the sound eye by sealing 
it hermetically with a layer of light rubber tissue cov- 
ered with a thin layer of cotton or gauze, which, with 
the rubber, is fastened by means of collodion to the skin 
surrounding the orbit. An opening for ventilation may 



GONORRHCEAL CONJUNCTIVITIS. 475 

be left at the outer side. Rubber plaster may be used 
instead of collodion, while for those who can obtain it 
promptly Buller's shield is the best device. 

In the beginning-, if the patient be strong and robust, 
several ounces of blood maybe abstracted from the tem- 
ple by means of leeches or cups, and a brisk cathartic 
may be administered. This treatment may be followed 
for several days by laxatives and a light diet. In a less 
vigorous patient these measures would be too severe, 
since it is very important that the general strength and 
the recuperative powers be maintained fully. In cachectic 
or debilitated subjects or in those with poor hygienic 
surroundings the task of trying to save the cornea is 
exceedingly difficult. 

The objects of local treatmentare(i)to keepthe surfaces 
clean and to prevent the accumulation of secretion be- 
neath the lids ; (2) to reduce congestion by the constant 
application of cold ; (3) to relieve pressure ; and (4) in 
all but mild cases to combat the process with applica- 
tions of astringent or caustic solutions. The accumula- 
tion of pus about the edges of the lids and under them 
should be wiped away gently with lint or with bits of 
cotton wrapped on the ends of toothpicks. Such lint, 
cotton, and toothpicks should promptly be burned. No 
dressing of any description should be used a second 
time. Safety for the patient's sound eye and for the 
eyes of the physician and the attendants demands that 
every piece of cloth or other dressing that has once 
come in contact with the smallest particle of the dis- 
charge should immediately be destroyed by burning. 

After the first cleansing further accumulation of pus be- 
neath the lids should be prevented by frequent washing 
with a 3 per cent, solution of boric acid in distilled or 



476 SYPHILIS AND THE VENEREAL DISEASES. 

boiled water. A solution of bichloride of mercury (l : 
20,000) may be used instead. The lids are gently sepa- 
rated, and the liquid is allowed to flow over the surfaces 
until all secretion is removed. The solution is best applied 
by sqeezing it out of pieces of cotton or sponge ; a bulb- 
syringe may be used, but the ordinary irrigating syringe 
is liable to spatter and to endanger the other eye. The 
patient's head should be turned sHghtly to the side of 
the affected eye, to prevent any possibility of the solu- 
tion reaching the opposite side, and a pus-basin or wads 
of cotton should be held in position to catch the dis- 
charge. This irrigation of the inflamed surfaces should 
be repeated every five, ten, or fifteen minutes, both day 
and night, during the acute stage, and less frequently as 
the discharge becomes less abundant. The object is to 
keep the surfaces, and especially the cornea, free from 
pus. 

During the intervals between the washings cold is 
applied by means of pieces of soft linen, large enough to 
cover the eye, taken out of ice-water or from the surface 
of a block of ice. These pieces of linen are removed 
and burned, and are replaced by fresh ones every minute 
or two. This constant dressing and handling of the eye 
must be done with the utmost care and gentleness, and 
should be made to interfere as little as possible with that 
physiological rest which is so greatly to be desired in 
any acute inflammation. The fingers should not come 
in contact with the globe, or, if possible to avoid it, with 
the edges of the lids. Pressure (of heavy dressings, etc.) 
should be prevented. If the upper lid is thick and tense 
and difficult to evert, thus preventing proper cleansing 
of the eye and producing pressure upon the cornea, can- 
thoplasty should be performed freely. The fingers or a 



GONORRHOEAL CONJUNCTIVITIS. 477 

wire speculum hold the lids apart and thoroughly stretch 
the skin over the outer canthus ; one blade of a pair of 
sharp, strong scissors is passed under the lid, and the 
point is carried to the bottom of the cul-de-sac ; a single 
sharp cut, which should be exactly horizontal, divides 
the tissues to the margin of the orbit. Pressure is thus 
relieved and free irrigation of the eye is made possible. 
If the parts heal too rapidly, it may be necessary to re- 
peat the operation. 

In mild cases frequent cleansing and the constant 
application of cold may be all the local treatment neces- 
sary. In most cases, however, when the conjunctiva 
becomes greatly swollen and the discharge profuse and 
purulent, a I or 2 per cent, solution of nitrate of silver 
should be used. If the cornea is clear, 2 or 3 drops of 
such a solution may be dropped between the lids ; but a 
better method is to evert the lids and apply a 2 (occasion- 
ally a 3 or 4) per cent, solution to the conjunctiva by 
means of a bit of cotton twisted on the end of a tooth- 
pick. After a few seconds the surfaces may be gently 
wiped dry or washed with a common salt-solution. By 
allowing the nitrate solution to remain on the conjunctiva 
a longer or shorter time the duration and extent of the 
caustic action, indicated by the whitening of the surfaces, 
can be controlled, and danger of irritating the cornea 
by contact with the fluid is avoided. In ulceration of 
the cornea the avoidance of such irritation is a matter 
of special importance. 

Following such an application the discharge is greatly 
lessened, though the swelling continues, and pain is tem- 
porarily increased. If the iced cloths do not relieve the 
pain, solutions of atropine or of cocaine may be used. 
After a few hours the discharge reappears and contains 



478 SYPHILIS AND THE VENEREAL DISEASES. 

fine shreds of the eschar resulting from the caustic. Fre- 
quent washings and another appHcation of the silver- 
solution are then in order. In the early stages of the 
affection solutions of the nitrate should be used but once 
in twenty-four hours; later they may be used every six, 
eight, twelve, or twenty-four hours, depending upon the 
rapidity with which the conjunctiva recovers from the 
application. Dr. Joseph A. Andrews has well empha- 
sized the fact that the caustic solution should not be 
used until the eschar produced by the previous applica- 
tion has disappeared entirely. The use of the nitrate of 
silver solution should always be preceded by a thorough 
washing of the surfaces, and may be followed at intervals 
of an hour or two by the free use in the eye of a pure 
vaseline. 

The cornea should be watched carefully. If it be- 
comes cloudy or ulcerates centrally, a solution of atro- 
pine (gr. ij to Bj) should be dropped in the eye often 
enough to keep the pupil well dilated. If ulceration be- 
gins at the margin, sulphate of eserine (gr. j to §j) should 
be used instead of atropine, and with sufficient frequency 
to keep the pupil tightly contracted, thus lessening the 
danger of prolapse of the iris in case of perforation. In 
exceptional cases, with pus in the anterior chamber and 
with bulging of the cornea, puncture (paracentesis) is 
advisable ; and occasionally it is necessary to relieve the 
pressure upon the cornea by free incisions into the 
chemotic conjunctiva. Such incisions should be made 
after, never before, application of the caustic solution. 

As the inflammatory symptoms subside and the dis- 
ease progresses toward recovery the treatment is less 
active, but careful watch of the eye must be maintained 
for fear of a relapse. In the declining stage, if the cornea 



OPHTHALMIA NEONATORUM. 479 

is clouded, absorption may be hastened by the use, for 
ten or fifteen minutes several times a day, of hot fomen- 
tations or irrigations ; in the intervals the use of cold 
cloths is continued. When the discharge has become 
slight the cold cloths may be given up and the surfaces 
may be brushed lightly every day or two with a i per 
cent, solution of nitrate of silver or of sulphate of zinc. 
Prognosis. — The prognosis is always grave, but it is 
least favorable in the cachectic or the feeble and in those 
who have had previous disease of the eyes. Noyes gives 
the result in 40 cases as follows: In 10 the cornea es- 
caped injury and recovery was complete ; of the other 30 
with involvement of the cornea, 5 retained useful vision, 
9 retained some vision, and 16 lost all vision, in the af- 
fected eye. The chronic (granular) conjunctivitis which 
often results usually yields to appropriate treatment. 

OPHTHALMIA NEONATORUM (BLENNORRHCEA 
NEONATORUM). 

The term " ophthalmia neonatorum " is applied to pur- 
ulent conjunctivitis appearing in children a day or two, 
or occasionally a few weeks, after birth. It is much more 
common than gonorrhoeal conjunctivitis in the adult, 
and is therefore of greater importance, but it is of interest 
chiefly to the obstetrician and the ophthalmologist. The 
condition is the result of direct or indirect infection of the 
child's eyes with secretions from the mother's vagina. 
This infection may occur during birth, but in most cases 
it probably occurs during the first washing of the child, 
or from accidental contact with sponges, napkins, hand- 
kerchiefs, etc. used by the mother. Indirect infection by 
some means is undoubtedly the cause of the disease 
when it appears after a few days. The source of infection is 



480 SYPHILIS AND THE VENEREAL DISEASES. 

not necessarily gonorrhoeal ; other pus or irritating secre- 
tions may produce in the child a conjunctivitis differing 
but slightly, if at all, from that produced by gonorrhoea. 

Symptoms.— The symptoms are essentially those of 
gonorrhoeal conjunctivitis in the adult; but the disease 
may be even more acute in its course, and loss of sight 
is possibly more frequent. 

Prophylaxis. — In case the mother have a suspicious 
vaginal discharge, her vagina should be cleansed with an 
antiseptic solution before the child is delivered. Imme- 
diately after birth the child's eyes should be washed thor- 
oughly with a 3 per cent, solution of boric acid, and a 
drop of a 2 per cent, solution of nitrate of sih-er should 
be dropped in each eye (Crede's method). If the result- 
ing inflammation be too severe, it may be limited by the 
application of cold. Every precaution should be taken 
lest the child's eyes be infected later, through the careless 
use of handkerchiefs, towels, etc. 

Treatment. — The treatment is practically that of the 
disease in the adult, except that the nitrate of silver 
should be used with greater caution and in weaker solu- 
tion (one-half per cent.), and be limited in its application 
to such cases as fail to improve under the use of frequent 
washing and iced cloths. It is even more important 
than in the adult that caustic solutions should be kept 
from the cornea. Canthoplasty is rarely required in the 
infant. Cachexia, debility, and lack of development (pre- 
mature birth) predispose to unfavorable results. 

Many children for a few days after birth have a mild 
form of conjunctivitis which gives the lids a red and 
sticky appearance. These cases call simply for occasional 
bathing in simple borax-water or alum-water, and should 
not be confounded with the purulent form of the disease. 



GONORRHCEAL INFLAMMATION, ETC. 48 1 

GONORRHCEAL INFLAMMATION OF THE REC- 
TUM AND THE MOUTH. 

A few well-authenticated cases are reported in which 
the mucous membrane of the anus, of the rectum, or of 
the mouth has been involved in a gonorrhoeal inflamma- 
tion. Such cases are, however, so rare that they may be 
classed among the curiosities of medical and surgical 
practice. The gonococcus does not readily invade these 
membranes, but when the disease does occur in these 
localities, it is undoubtedly due to local infection with 
gonorrhoeal pus, and not, as has been suggested, to met- 
astasis. Infection may be the result of accident or un- 
cleanliness in those suffering from gonorrhoea, or it may 
be due to unnatural coitus. 

Occurring in the anus and the rectum, the disease be- 
gins with itching and burning sensations which rapidly 
increase in intensity until, in a few days, pain is constant 
and greatly increased on defecation. The membranes 
become intensely red, hot, congested, and swollen, and 
secrete at first a thin, creamy discharge, which soon be- 
comes thicker, darker, and profuse. The inflammation 
is usually limited to the anus or to the membrane below 
the internal sphincter. The diagnosis between gonor- 
rhoeal and other forms of proctitis will rest chiefly upon 
the discovery of gonococci in the discharge and upon 
the history. In women the cause may be found in a 
gonorrhoea of the vagina or the urethra, the discharge 
from which has been allowed to run down over the anus 
and infect the membrane. When the disease occurs in 
one who has practised sodomy for some time, the sphinc- 
ters are relaxed, the anal folds are wanting, and the anus 
may be more or less funnel-shaped. 

31 



452 SYPHILIS AND THE VENEREAL DISEASES. 

If limited to the anus, the disease should be treated 
simply with cleansing and astringent lotions and powders, 
and the surfaces should be separated with soft dressings, 
the principles and details of treatment being essentially 
those recommended for balanitis. Excoriations, fissures, 
and superficial fistulae may be touched with solutions (or 
the solid stick) of nitrate of silver. If the disease extends 
into the rectum, care should be taken to secure a reg^ular 
daily evacuation from the bowel, and the rectum should 
be irrigated thoroughly once or twice daily with a warm 
saturated solution of boric acid. For this purpose the 
rectal irrigator devised by Dr. James P. Tuttle is desirable. 
It may be necessary to dilate the sphincters and to apply 
a solution of nitrate of silver to excoriations and super- 
ficial ulcers that may be present. 

Gonorrhoeal inflammation of the mucous membrane 
of the mouth has been reported in very few instances, 
the largest number of cases being in new-born infants 
undoubtedly infected during birth by vaginal discharges. 
The symptoms are those of a severe stomatitis. The 
diagnosis is made from the history and by the finding of 
gonococci in the discharge. In new-born children the 
disease appears much earlier than do other forms of 
stomatitis. The treatment consists in frequent washing 
of the mouth with warm saturated solutions of boric 
acid (the addition of slippery elm or of flaxseed to the 
solution is sometimes very grateful), and in the applica- 
tion to the surface of astringent solutions. Nitrate of 
silver in strength varied to meet the indications of each 
case is the best preparation. 

Gonorrhoeal inflammation of the nose has been men- 
tioned by several writers, but an unquestionable case has 
not been reported. 



CHRONIC URETHRITIS. 



Synonyms. — Chronic gonorrhoea; Gleet. 

Before terminating in complete recovery every case 
of acute urethritis passes through a subacute stage with 
a muco-purulent and finally a mucous discharge. Fol- 
lowing a first attack of gonorrhoea, in a healthy man 
under favorable hygienic surroundings, this muco-puru- 
lent stage tends to recovery without local treatment ; 
but when following repeated infections, or an infection in 
an unhealthy individual or in one subjected to improper 
treatment or other injurious influences, this subacute 
stage may be prolonged indefinitely, and is known as 
" chronic urethritis " or " gleet." 

Etiolog-y. — In the cachectic, chronic urethritis may 
occur independently of an acute attack ; but almost all 
cases originate in gonorrhoea. 

The influences which interfere with the proper re- 
covery of gonorrhoea and which tend to prolong the dis- 
ease in chronic form are numerous and vary widely in 
different individuals. The general health of the patient 
is an important factor. In gouty, rheumatic, strumous, 
syphilitic, tubercular, anaemic, or debilitated persons it is 
not unusual for gonorrhoea to be followed by chronic 
urethritis. It occurs frequently as a result of repeated 
infections, or after a first infection in which there have 
been a series of relapses. 

483 



484 SYPHILIS AND THE VENEREAL DISEASES. 

Probably the chief factors in the production of chronic 
urethritis he in the failure of the patient to observe a 
proper sexual hygiene during and after an attack of gon- 
orrhoea; and the most persistent and intractable cases 
are found in men who, in spite of their disease, are in- 
dulging in promiscuous sexual relations, or who are 
subjecting themselves to other forms of sexual excite- 
ment, or who, in their efforts to get well, are constantly 
irritating the urethra by improper or excessive treat- 
ment. Mention has already been made of the fact that 
the cessation of a urethral discharge does not necessarily 
mean that the urethra has returned to a normal condi- 
tion. It is difficult to make the average patient under- 
stand this fact, and realize the necessity of his living 
hygienically for some weeks or months after his gonor- 
rhoea is apparently cured. Offenders of one class resume 
sexual relations as soon as the discharge becomes in- 
visible. Such men often incur fresh infection, and have 
within a few months a series of gonorrhoeas some one of 
which will surely terminate in the chronic form ; or, if 
fortunate enough to escape fresh gonorrhoeal infection, 
nevertheless the recently inflamed mucous membrane of 
the urethra becomes the seat of small areas of chronic 
congestion and infiltration, resulting in a gleety dis- 
charge. Others, without sexual intercourse, indulge in 
sexual excitement, physical or mental, which aggravates 
the congestion of the parts and does not permit the rest 
necessary for a complete recovery. 

Alcohol and tobacco are irritants to the mucous mem- 
brane of the urethra, and if used during the course of gon- 
orrhoea or urethritis tend to prolong the disease. The 
resumption of their use too soon after the apparent cure 
of an inflammation of the urethra is many times responsi- 



CHRONIC URETHRITIS. 485 

ble for a return of the discharge ; while many subacute 
cases refuse to get well until the patient abandons his 
habits in this particular. Similar in effect to the use of 
alcohol and tobacco, though in lesser degree, are excesses 
in eating, especially of nitrogenous and highly seasoned 
foods. Imperfect digestion, followed by incomplete as- 
similation and metabolism, necessitates the elimination 
through the urine of products foreign to normal urine, 
and therefore irritating to the urethral mucous membrane. 
Imperfect functional activity of the skin and the bowels, 
by adding to the quantity of solids in the urine, and there- 
fore to its irritating qualities, may retard the recovery of 
a urethritis. Excessive physical exercise, while not so 
harmful as in acute urethritis, sometimes exerts a dele- 
terious influence upon a chronic discharge. 

A frequent source of chronic urethritis lies in exces- 
sive and ill-advised treatment, the patient trying one in- 
jection after another, using sounds, soluble bougies, and 
other forms of local and internal treatment, in hopes of 
removing the last trace of his discharge. These cases 
are most frequently found in unmarried men who are 
greatly worried about themselves and who drift from 
one physician to another. They try the " infallible " 
prescriptions recommended by their friends, and in the 
course of their wanderings they sooner or later fall into 
the hands of charlatans, and submit to all sorts of opera- 
tions and treatment. If properly advised in time, before 
operative procedures have damaged the tissues, many of 
these cases recover completely as a result of simply sus- 
pending all treatment and living hygienically. 

When the mucous or muco-purulent stage has lasted 
for some weeks, or when there has been a series of re- 
lapses, the disease usually becomes localized. The 



486 SYPHILIS AND THE VENEREAL DISEASES. 

greater portion of the urethral mucous membrane re- 
covers its normal condition, but certain circumscribed 
areas become the seat of chronic congestion and infiltra- 
tion, or some of the complications which have arisen 
become persistent. The causes of this localization lie 
largely in the anatomical structure of the different parts 
of the genito-urinary tract. The inflammatory process 
naturally becomes more firmly seated in those portions 
well supplied with follicles, glands, and vessels. For 
this reason the prostatic, if once infected, and bulbous 
portions of the urethra and the fossa navicularis are 
especially liable to the persistent forms of inflanmiation 
and congestion. In most cases of chronic urethritis some 
portion of the anterior urethra is involved. 

Among the local conditions which may exert an un- 
favorable influence upon chronic urethritis or be respon- 
sible for its persistence are areas of congestion and in- 
filtration in the urethra, stricture, hypertrophy of the 
prostate, prostatitis, vesiculitis, lacunal inflammation, 
Cowperitis, folliculitis, periurethral abscess, fistulae with 
internal openings, mucous patches in the urethra, and 
local tuberculosis. 

The role of the gonococcus in the etiology of chronic 
urethritis is not yet definitely determined. These micro- 
organisms can be demonstrated in many cases, but they 
are present in small numbers, and often can be found 
only after repeated examinations ; while in quite a per- 
centage of cases repeated careful examinations fail to 
show the gonococci. It would seem that the patho- 
logical processes instituted by the gonococcus may con- 
tinue after the disappearance of the latter. 

Symptoms. — The symptoms of chronic urethritis vary 
with the individual, the duration of the disease, and its 



CHRONIC URETHRITIS. 487 

location. In recent cases and in those undergoing 
active local treatment there is usually, in addition to the 
circumscribed pathological process, more or less conges- 
tion and catarrhal condition of the mucous membrane 
of the entire urethra, resulting in a mucous discharge 
which may be sufficient to stain the linen, or, if the pre- 
puce be long, to keep its inner surface and that of the 
glans constantly moist ; or there may be a subacute in- 
flammation with a muco-purulent discharge. 

In old cases in which most of the urethral mucous mem- 
brane is healthy and the disease is confined to one or more 
small areas, two or three drops of mucus or of muco- 
pus collect in the urethra during the night and are seen 
at the meatus by the patient on rising in the morning. 
During the day, when the urethra is washed out more 
frequently by the passage of urine, the collection is 
usually only sufficient to cause slight moisture of the 
lips of the meatus or to slightly glue them together ; or 
there may be no evidence of discharge during the day, 
and but an occasional agglutination of the lips of the 
meatus in the morning ; or, finally, there may be no 
symptoms noticeable by the patient while he is living a 
regular life, though sexual indulgence or the use of 
alcohol or tobacco, or even excesses in eating or in ex- 
ercising, may cause a prompt return of the discharge. 
These relapses are frequently considered new, mild in- 
fections, but they differ from the latter in that the symp- 
toms appear at once, without any period of incubation, 
and subside in a i^^si days under simple treatment. 
Sometimes the only evidence of disease is that found in 
the urine, which may be clouded with pus and mucus 
from the posterior urethra, or may be clear except for 
shreds composed of mucus, epithelium, and pus-cells. 



SYPHILIS AND THE VEXEREAL DISEASES. 

Subjective sensations are often entirely wanting, 
though the condition may persist for months or years. 
More frequently the patient experiences, while urinat- 
ing, slight burning, pricking, or tingling sensations 
along the urethra or at the site of the lesions. In 
disease of the posterior urethra there may be a feeling 
of warmth, fulness or weight in the perineum, with pos- 
sibly some increased frequency of urination, or even 
sHght tenesmus ; and if, as frequently happens, the in- 
flammation invades the glands and the tissues of the 
prostate, there may be added all the distressing symp- 
toms, both physical and mental, of chronic prostatitis. 

If the process extends beneath the mucous membrane 
of the urethra, stricture may follow, with all its symp- 
toms. If one or more follicles or glands of the urethra 
or the periurethral tissues are involved, the symptoms 
will depend upon the activity of the inflammation in 
these structures. 

Pathology. — Regarding the pathology of chronic 
urethritis. Finger, who has made a histological study 
of a large number of cases, arrives at the following 
conclusions : 

" I. Chronic urethritis is a focal process which runs 
its course as a chronic hyperplasia in the subepithelial 
connective tissue. Disease of the epithelium and glands 
is to be regarded in part as a complication, in part as a 
sequel. 

" 2. The foci of chronic blennorrhoea are localized 
preferably in the pendulous portion, the bulb, and the 
prostatic portion. 

" 3. The membranous portion is relatively immune to 
the chronic process. 

"4. In a series of cases the foci of chronic inflamma- 



CHRONIC URETHRITIS. 489 

tion in the pars anterior and posterior are situated super- 
ficially in the mucous and subepithelial connective tissue. 

" 5. In another series of cases these foci extend by 
continuity to the submucous tissue — in the pars anterior, 
to the periurethral and cavernous spongy tissue ; in the 
pars posterior, to the prostate. 

" 6. This results in complicating focal processes — 
chronic periurethritis in the pars anterior, prostatitis in 
the pars posterior. 

" Hence arises the following classification of chronic 
urethritis : 

" I. Chronic anterior urethritis : (/?) Superficial anterior 
chronic urethritis ; {b) deep anterior chronic urethritis 
(that is, plus chronic periurethritis). 

" II. Chronic posterior urethritis : [a] Superficial chronic 
posterior urethritis ; (//) deep chronic posterior urethritis 
(that is, plus chronic prostatitis). 

" As a matter of course, mixed forms are frequent — 
that is, various foci in the pars anterior and posterior. 

" The relation of gonococci to chronic urethritis is 
extremely obscure. . . . Their virulence is weakened 
by long proliferation upon the same soil for many gen- 
erations. As proof may be cited the fact that chronic 
blennorrhoea is often conveyed as chronic, much more 
rarely as acute, blennorrhoea. The fact that each suc- 
ceeding relapse is milder and shorter also indicates that 
the irritation of the papillary body by the gonococci 
gradually diminishes. The first relapses will always 
terminate by the removal of the gonococci to the sur- 
face, but the virulence may finally be diminished to such 
an extent that the acute purulent symptoms on renewed 
invasion of the papillary body no longer suffice to carry 
the gonococci to the surface. They will then remain in 



490 SYPHILIS AND THE VENEREAL DISEASES. 

the papillary body, perhaps also in the follicles, and by 
their constant slight irritation give rise to the chronic 
proliferating processes in the mucous membrane. The 
conveyance of these enfeebled gonococci would explain 
the ab initio chronic infection in women ; and their pro- 
liferation in the deep layers enables us to understand the 
fact that gonococci may or may not be found in the 
secretion, the clap-shreds. But the chronic changes 
induced by the gonococci may develop further after the 
cocci have perished from any cause. This explains the 
fact that in certain chronic blennorrhceas we find the 
secretion and clap-shreds, but no gonococci." 

Diag-nosis. — The symptoms of chronic urethritis are 
usually so evident that a diagnosis of urethritis is readily 
made. The difficulty lies in determining the seat and 
nature of the pathological process. The diagnosis be- 
tween an exacerbation of a chronic urethritis and a re- 
cent mild infection is not difficult when it is remembered 
that the former appears in a few hours after exposure, 
without any period of incubation, is generally attended 
by no symptoms other than a trifling discharge, subsides 
readily under mild treatment, and has been preceded by 
other similar relapses of more or less recent date. 

Chronic prostatitis may exist independently of ure- 
thritis, and may present symptoms identical with those 
of the same disorder when it complicates posterior ure- 
thritis. The diagnosis will depend upon the history and 
the absence of other evidences of urethral disease. 

The adhesion of the lips of the meatus or the appear- 
ance of an occasional drop of mucus does not necessarily 
indicate urethritis. These symptoms may appear as a 
result of hypersecretion of mucus by a congested ure- 
thra. This condition is found in patients who are irritat- 



i 



CHRONIC URETHRITIS. 49 1 

ing the mucus membrane of the urethra with needless 
injections or instrumentation. It is also found in per- 
sons who commit sexual excesses, natural or unnatural, 
or who indulge in ungratified sexual excitement. Under 
these circumstances the congestion and hypersecretion 
of mucus which always attend an erection become more 
or less persistent. Under the microscope such a dis- 
charge is seen to be composed of mucus and epithelial 
elements. The absence, on repeated examinations, of 
pus-cells and gonococci excludes urethritis. 

The Infectiousness of Chronic Gononlioea. — The discov- 
ery of characteristic gonococci in the secretion or shreds 
from the urethra at once determines the case to be one 
of chronic gonorrhoea. But in the majority of cases of 
chronic urethritis demonstration of the gonococci is not 
easy, since they are usually present in small numbers 
and associated with other micro-organisms. In a given 
case drops of pus and shreds may be examined for a 
number of days without discovering the gonococci, 
which a few days later may be found in considerable 
numbers. Negative findings are not conclusive, and so 
long as the secretion contains pus, the presence of gono- 
cocci should be suspected and sought for. In exacerba- 
tions of chronic urethritis the gonococci increase in 
numbers and can more readily be demonstrated ; hence 
it may be justifiable, when repeated examinations give 
negative results, to cause an artificial inflammation of the 
urethra for the purposes of diagnosis. In anterior ure- 
thritis this object can be accomplished by irrigating' the 
pars anterior a few times with a solution of bichloride in 
strength of i : 20,000 or I : 10,000. In posterior urethri- 
tis a few drops of a i per cent, solution of nitrate of 

' See L'rigation (index). 



492 SYPHILIS AND THE VENEREAL DISEASES. 

silver may be placed in the deep urethra with a Keyes 
syringe. The increased (purulent) secretion which re- 
sults will usually show gonococci if these be present. 
There are cases of urethritis in which artificial exacerba- 
tion of the disease and repeated examinations of the 
secretion fail to demonstrate the gonococci. The secre- 
tion in such cases is rarely anything more than mucus, 
and is the product of a catarrhal process in an over- 
stimulated mucous membrane. 

It is evident that with a chronic urethritis in the secre- 
tion of which gonococci are present but occasionally, a 
man may indulge in sexual intercourse repeatedly with- 
out infecting his partner, though he has no means of 
knowing at what time his discharge may become infec- 
tious. It is not safe, therefore, to allow a man with 
chronic urethritis to marry, or, if married, to resume 
marital intercourse, until during several weeks of fre- 
quent examinations the discharge shows no gonococci 
and the clinical symptoms point strongly to the presence 
of nothing more than a catarrhal discharge. 

On this subject Finger says : " I permit a patient who 
is suffering from chronic blennorrhoea — that is, the morn- 
ing drop or clap-shreds — to have marital intercourse only 
after I have convinced myself, by a two to four weeks' 
daily examination of the secretion or clap-shreds, that 
these contain only epithelium, and no pus-cells, and when, 
after irrigation of the urethra with a solution of silver 
nitrate or corrosive sublimate, and consequent suppura- 
tion, the secretion is entirely free from gonococci, and 
there is no further indication for the continuance of 
treatment. The conditions v>'hich I require are, accord- 
ingly, the absence of gonococci, pus-corpuscles, and peri- 
urethral complications." 



I 



CHRONIC URETHRITIS. 493 

Noeggerath believes that if a man once have a 
urethral discharge containing gonococci, he never 
fully recovers, and that nine-tenths of the women mar- 
ried to men who have had gonorrhoea eventually 
develop pelvic inflammation due to infection by the 
gonococci. Such inflammations are usually subacute 
in their origin, and often date from the birth of the first 
child. On the other hand, Keyes, in his treatise of 1888, 
says : " Care must be exercised in advising marriage, if 
the discharge be at all purulent and contain gonococci. 
No such pus can be pronounced free from contagious 
properties, although, practically, in my experience it has 
sometimes turned out to be so. In all cases of pro- 
longed purulent gleet a lesion in the urethra (strictures, 
granulations) should be sought for and treated. If not 
found, and if no gonococci are present, marriage is 
proper, and not only not harmful, but even beneficial, 
in its effect upon the discharge." 

Localization of Lesions. — In all cases of chronic 
urethritis it is necessary to determine the extent, loca- 
tion, and nature of the pathological process. In the 
majority of cases this is limited to small circumscribed 
areas, but in more recent cases, and in those giving a 
history of frequent relapses or continued local treatment, 
the entire mucous membrane may be the seat of a sub- 
acute inflammation, or at least of a chronic congestion. 
When a large portion of the urethra is thus involved, 
there will be a more abundant secretion, and the urine 
containing the washings of the urethra will be cloudy 
from the presence of pus or of mucus. Examination 
with in.struments for the local lesion should be postponed 
until the more general disturbance has been removed by 
proper treatment. 



494 SYPHILIS AND THE VENEREAL DISEASES. 

The first step in locating the seat of a chronic urethri- 
tis is to determine if it be in the anterior or the posterior 
urethra. 

1. History and Symptoms. — If there be a history of 
epididymitis, prostatitis, cystitis, vesicuhtis, tenesmus, or 
other symptoms pointing to a former acute posterior 
urethritis, it is quite probable that in the posterior 
urethra will be found the lesion responsible for the 
chronic disorder. Subjective sensations are usually 
insignificant or wanting in chronic urethritis of the pars 
anterior, but if the pars posterior be involved there are 
usually ill-defined sensations and pains in the perineal 
region, and sensitiveness of this portion of the urethra 
on pressure upon the perineum or through the rectum ; 
there may be frequency of urination, tenesmus, and 
other symptoms pointing to the presence of chronic 
prostatitis. 

2. TJie Discharge. — If the discharge arises from some 
portion of the pendulous urethra, it will gravitate to 
the meatus, and appear there occasionally as a yellow- 
ish, milky, or transparent drop, or it may lightly glue 
together the lips of the meatus. When the process is 
situated in the bulb, the discharge, if small in amount, 
may remain in situ until washed out by the urine. Dis- 
charges arising from the pars posterior will not appear 
at the meatus during the intervals of urination, but will 
remain in the prostatic portion or will pass backward 
into the bladder. 

3. Examination of Urine. — When the pathological 
process has become limited to circumscribed areas, 
neither pus nor mucus will accumulate sufficiently to 
appear as a discharge or to render the urine cloudy, 
but the urine may contain flakes or shreds composed 



CHRONIC URETHRITIS. 495 

of mucus, pus, and epithelium. The shreds may be 
transparent, delicate, narrow threads, often very long 
and branched. These threads are composed chiefly 
of mucus and epithelium, show a tendency to float in 
the urine, and in general indicate superficial and milder 
lesions of the urethra. Other shreds are shorter, firmer, 
and opaque, and contain a greater number of pus-cells. 
Such shreds sink rapidly to the bottom and indicate 
a more serious condition. A third type of shreds is 
sometimes found in the form of short, firm, comma- 
like plugs or flocculi. These particles come from 
the excretory ducts of the various glands and follicles 
of the urethra that may be involved in the process. The 
character of the shreds gives some clue to the nature 
and intensity of the urethral disorder, but does not 
give reliable information regarding the location of the 
lesion. If, however, the shreds contain spermatozoa, or 
if they are of the comma-like variety and are present in 
the second portion of the urine, they come from the 
prostatic urethra. 

The urine should be examined by the two-glass 
method, though this test is of less value than in acute 
urethritis, since the small amount of pus formed in the 
posterior urethra will be removed in the act of urinating 
before sufficient has accumulated to pass back into the 
bladder, and during the day, while the urine is passed 
at frequent intervals, that in the second glass will be 
clear and free from shreds. But if the urine be retained 
several hours until the prostatic urethra is well dilated, 
forming practically a part of the bladder, the pus and 
the shreds will mix with the urine in the bladder and 
appear in the second glass. Hence it is important that 
the patient bring his morning urine passed in two bottles, 



496 SYPHILIS AND THE VENEREAL DISEASES. 

and that he again urinate in two glasses at the time of 
his visit to the physician. Another condition may be 
present, even when the urine in the bladder is clear, to 
cause cloudiness and shreds in the second glass : if the 
prostatic glands are inflamed, pus and comma-like plugs 
may be pressed out by the contraction of the muscle at 
the close of urination, appearing with, or just after, the 
last drops of urine. 

The two-glass test may be modified by first cleansing 
{irrigating) the anterior urethra with some simple aseptic 
or mildly antiseptic solution. A 6 per cent, solution of 
sodium chloride, or bichloride of mercury in the strength 
of I : 50,000, or boric acid, may be used. The reservoir 
holding the fluid should be but two or three feet above 
the level of the penis, and should be connected, by 
means of rubber tubing, with a short glass or hard- 
rubber tube. The latter may be inserted into the 
urethra about an inch, and should not be large enough 
in diameter to completely fill the meatus, since space 
must be left by the side of the tube for the solution to 
escape. The fluid may then be allowed to flow until 
the pars anterior has been entirely cleansed of all pus, 
mucus, and shreds. If the patient now urinate in two 
glasses, the first glass will contain the washings of only 
the pars posterior ; consequently, if the urine in both 
glasses be clear, it is evident that the disease is limited 
to the pars anterior ; but if the urine in the first glass 
contain dus or shreds, while that in the second p;lass is 
clear, it is safe to make a diagnosis of posterior ure- 
thritis. If the urine in both glasses contain pus and 
mucus, inflammation of the bladder or of the kidneys 
is probably present. In this case other examinations 
should be made, and especially of urine that has been 



CIIROXIC URETHRITIS. 49/ 

retained in the bladder but a short time. If the second 
glass at any time shows clear urine, cystitis may be 
excluded. 

The reservoir should not be placed at too great an 
elevation, and the lips of the meatus should not be held 
against the tube to interfere with the free outflow, or the 
pressure upon the compressor urethrse muscle will be 
sufficient to cause it to relax, and the fluid will pass on 
into the bladder, carrying with it pus and shreds from 
the pars anterior. The object of the test will thus be 
defeated, since the urine in the bladder — and therefore 
that in both glasses — will contain the washings of the 




Fig. 17. — Kiefer's urethral irrigation nozzle (Tiemaun). 

pars anterior. A Keifer nozzle (Fig. 17) or a double 
recurrent catheter may be used, but is not essential. 
Instead of the short tube a soft catheter may be em- 
ployed. The tip should be introduced no further than 
the bulb of the urethra. 

A simpler method of locating the origin of shreds 
in the urine is found in completely filling the ante- 
rior urethra by means of a gonorrhoeal syringe with 
a solution of methylene-blue or other stain. This 
solution is left in the urethra for one or two minutes and 
is then allowed to escape. The patient should now 
urinate in two glasses. The first portion of urine may 
thus contain shreds from all parts of the urethra, but 

32 



49^ SYPHILIS AND THE VENEREAL DISEASES. 

those from the pars anterior will be blue, while those 
from the pars posterior will be unstained. 

4. Examination with Sounds and Bougies. — In a large 
proportion of cases of chronic urethritis stricture in 
some form is present, and in an instrumental examina- 
tion of the urethra is the first thing to be searched for. 
A detailed description of instruments and methods used 
for this purpose is given in the discussion of Stricture, 
and is not repeated here. 

When no stricture can be found, other forms of local 
lesions that may be present can often be located accu- 
rately by means of the steel sound or the rubber bougie. 
It is always well to begin with a blunt steel sound of the 
largest size that will easily pass the meatus. This larger 
sound, warmed and oiled, causes less pain than smaller 
ones, and will often answer every purpose. The sensa- 
tions of the patient on the first passage of any sound 
should not be relied upon for the location of diseased 
areas, as the entire mucous membrane is often so sensi- 
tive that the patient, usually nervous and apprehensive 
in this his first experience with a sound, cannot tell 
definitely at what points the passage of the instrument 
causes him the most pain. In most cases all decided 
pains disappear when the sound ceases to move, and it 
should be held quietly in the urethra for from one to 
five minutes until the sensitiveness of the membrane is 
lessened and the fears of the patient are overcome, when 
it should be withdrawn gently and at once reintroduced, 
gently and slowly. Its second introduction will cause 
the patient comparatively little uneasiness except when 
the tip of the instrument comes in contact with areas of 
disease (inflamed follicles, granular patches, or superficial 
ulcers). At these points he will probably experience the 



CHRONIC URETHRITIS, 499 

sensation of burning or sharp, sticking pains. With the 
sound held in the urethra with one hand, the finders of 
the other hand may explore the pendulous portion and 
accurately locate areas of thickening and sensitive 
points. 

In disease of the pars posterior or of the prostate 
gland passage of the sound through the deep urethra 
may be accompanied by great pain and violent tenes- 
mus. If relief does not quickly follow when the sound 
is held still, it should at once be withdrawn from this 
part of the urethra. In neurasthenics and in cases of 
urethral hyperaesthesia the first attempts to sound the 
urethra may be very painful, the muscular fibres of the 
urethra contracting about the instrument, forming spas- 
modic strictures which interfere with the passage of the 
sound. In these cases patience, gentleness, and repeated 
examinations are often required before the limited areas 
of disease can be located or before the sound can be 
passed fully into the bladder. 

In less sensitive urethras, when the blunt sound fails 
to accurately locate the urethral lesions, the bulbous 
bougie or the urethrometer may be used. The largest 
sized bulbous bougie that can readily be introduced is 
oiled and passed to the deep urethra. It is then slowly 
withdrawn, and as the shoulders of the bulb come in 
contact with granulating and other sensitive areas the 
patient experiences sharp pains or sticking sensations. 
If on repeated examinations the patient complains of 
pain at the same points, the lesions are thus located.^ 

5. Endoscopic Examination. — Some few conditions of 
the urethra, such as tumors, polypi, granular patches, 

^ For a description of sounds and bougies, and the technique of their 
use, see Stricture. 



500 SYPHILIS AXD THE VENEREAL DISEASES. 

and ulcerations, are best recognized and treated by means 
of the endoscope. Tiiis instrument has a somewhat re- 
stricted field of usefulness, since its successful employ- 
ment calls for much experience and practice on the part 
of the operator, and the introduction of the straight en- 
doscopic tubes is attended by much more pain and irrita- 
tion of the urethra than is caused by the passage of sounds. 
The endoscope should never be used during acute, or even 
subacute, stages of urethritis, for fear of aggravating the 
existing inflammation. It is of service chiefly in those 
cases of chronic urethritis in which other methods of 
diagnosis and treatment have proved insufficient. It is 
always well to postpone the use of the endoscope in any 
case until the sensitiveness of the urethra has been tested 
and lessened by the use of sounds. 

{a) Description of Iiistmnients. — Since Desormeaux 
first made practical use of the endoscope in 1853, numer- 
ous modifications of his instrument have appeared, as 
well as some entirely new devices for exposing to view 
the mucous membrane of the urethra. The method rec- 
ommended by Gruenfeld, and the one most frequently 
employed, is the simplest, the endoscopic tubes being 
separate from the illuminating apparatus. Gruenfeld's 
original tubes have been modified by Steuer, and again by 




Klotz's endoscope (Tiemann). 



Klotz (Fig. 18). Either of the two modifications is prob- 
ably better than the original tube, since the flat disk 



CHR ONIC VRE THRl TIS. 



501 



prevents painful distention of the meatus when the tube 
is forced back upon the glans, thus shortening the penis 
and allowing inspection of the entire urethra by a tube 
much shorter than the urethra itself Tubes should be 
of metal or of hard rubber. In many respects the Klotz 
tube of coin-silver is best, since it is light, easily cleaned, 
and has thin walls, which allow a wider bore for the same 
size of tube. 

The tubes needed will vary in diameter from 16 to 30, 
French scale, and in length from three to five and a 
half inches. As a rule, a tube of the largest diameter 
that will pass the meatus should be used, in order to 
give the best illumination and the largest view possible. 
In the pendulous urethra specula (Figs. 19 and 20) 
may be used instead of tubes. They have an advantage 




Fig. 19. — Urethral speculum (Tiemann). 




Fig. 20.— Urethral speculum (Tiemann). 

over the latter in displaying larger areas at a time, but 
the pressure produced by the sides of the instrument 
causes more or less anaemia of the mucous membrane, 
and consequently modifies its appearance. 

Illumination is obtained by means of an ordinary mir- 



1 



502 SYPHILIS AND THE VENEREAL DISEASES. 

ror such as is used in examinations of the larynx. This 
may be fastened to a handle or, better, to a head-band. 
The source of light, in order of desirability, may be 
direct sunlig-ht, bright diffused davlioht, electric or eras 
light, or a kerosene lamp. If an artificial light is used, 
it should be mounted on a freely movable and adjusta- 
ble bracket. The addition of a condenser will improve 
the illumination. An excellent apparatus is that devised 
by Dr. F. Tilden Brown (Fig. 21). 




Fig. 21. — Brown's method of illuminating the urethra. 



In another type of endoscope the tube is directly con- 
nected with an electric illuminating apparatus. The 
Leiter electro-endoscope, used and recommended by 
Finger, has been modified by several operators in America. 
The Otis electro-urethroscope (Fig. 22) is probably as 
serviceable as any endoscope of this type. It has the 



CHRONIC UREl'HRITIS. 



503 



great advantage of being but one-sixth as heavy as 
Leiter's instrument. 

{U) Method of Examination. — For endoscopic examina- 
tion of the urethra the patient should be placed on a table 
or an operating-chair that will bring the genitals on a 
level with the eyes of the operator, who sits in front. If 
a separate reflector is used, the rays of light should come 
from a little to one side of the patient, and should so 
strike the reflector that the best possible illumination of 
the urethra may be obtained. Cotton, tampons, and 




Fig. 22. — W. K. Otis's "perfected" urethroscope (Tiemann). 

tampon-carriers (in the form of long wires or thin strips 
of wood, that can be thrown away after using once) 
should be within easy reach of the operator. With the 
penis at an angle of from 90° to 130° with the abdomen, 
the warmed and well-oiled tube, with its proper obturator, 
is directed along the upper wall of the urethra to the 
V bulb, where it meets with resistance. The tube is now 
in position to begin examination of the pars anterior. 
If the pars posterior is to be examined, the proximal 

I (ocular) end of the instrument is depressed and gently 
pushed on until the visceral end enters the neck of the 



504 SYPHILIS AXD THE VEXEREAL DISEASES. 

bladder, when partial removal of the obturator will allow 
some escape of urine if the bladder be moderately full, 
and the position of the tube is thus easily demonstrated. 
The tube is then withdrawn slightly, to the prostatic ure- 
thra, and the examination is begun. The passage of the 
straight instrument through this portion of the urethra 
is painful, and is also difficult of execution — sometimics 
impossible. In some men it will be necessary to depress 
the ocular end of the tube but to a horizontal line, while 
in others it must be carried much lower and consider- 
able force must be employed. As a rule, it is not wise 
to attempt an endoscopic examination of the pars pos- 
terior during the first visit of a patient or before the 
pars anterior has been inspected carefully. 

In making an endoscopic examination the tube should 
be inserted to the deepest part to be examined, and then 
slowly withdrawn, the operator cleaning and inspecting 
each portion of the mucous membrane as it comes in 
view at the distal end of the tube. 

[c) Appearance of the Normal Uretlira. — To use the 
endoscope successfully the operator must be familiar 
with the appearances of the different portions of the 
normal urethra. Such knowledge can come only 
through much experience, and cannot be gained solely 
from written descriptions, or even from plates. In the 
normal condition the urethra is not a tube with a definite 
calibre, but is a closed valve, the walls being in contact 
and h'ing in longitudinal folds. The introduction of 
the endoscopic tube separates the walls and smooths 
out the folds. A short distance from the end of the 
tube, however, the walls again come together in the 
form of a funnel, the folds radiating to a central point 
or a short line which has much the appearance of a 



CHRONIC URETHRITIS. 505 

sphincter and is called the " central figure." As the 
tube is slowly withdrawn the funnel follows, but if the 
tube be pushed backward, or if the one employed be 
too small for a given urethra, the folds of mucous mem- 
brane will fall together directly at the end of the tube, 
or will even project into it. 

In the posterior portion of the prostatic urethra the 
tunnel is short and the surface is smooth or but slightly 
ridged and of a dark-red color. As the tube is with- 
drawn the membrane becomes paler, and a flat or 
rounded protuberance appears at the lower edge of the 
tube. This protuberance gradually increases in size 
until it occupies about three-fourths of the field of 
vision, and the funnel above appears in the form of 
a crescent. The protuberance is formed by the collicu- 
lus seminaiis, on the summit of which, in favorable cases, 
may be seen the opening of the utricle. On further 
withdrawing the tube the colliculus gradually disappears, 
but its prolongation may remain in the field until the 
bulb is reached. On either side of the colliculus is a 
deep furrow. The tube may pass through one of these 
furrows, so that the colliculus is not seen at all or 
appears at one side. The picture obtained in the pros- 
tatic urethra is a complicated one, and differs greatly in 
different individuals. 

In the membranous urethra the mucous membrane is 
paler in color than in the prostatic portion, and the fun- 
nel is short and regular, the " central figure " being a 
point. In passing to the bulbous portion the picture 
may change gradually and but slightly, though more fre- 
quently the funnel becomes shorter and the folds much 
larger. The latter may push into the tube in the shape 
of two external ridgres which touch in the centre and 



5o6 SYPHILIS AND THE VENEREAL DISEASES. 

give the central figure the form of a vertical line or 
fissure. The contractions of the bulbo-cavernosi and 
ischio-cavernosi muscles may render it difficult to keep 
the tube in the bulb. This object can be accomplished 
by the use of force or by elevating the ocular end of the 
instrument as in the removal of a sound. 

In the pendulous urethra the funnel is again regular, 
the folds uniting in a central figure in the form of a hori- 
zontal slit. The color of the membrane is pink or pale 
red. Along the upper wall may be seen small, pin-point- 
sized depressions. These are the lacunae Morgagni. In 
the glans the central figure is triangular, except in the 
fossa navicularis, where it is vertical. The membrane 
loses some of its red color and adds a bluish tint. At 
the meatus it is of almost a slate color. 

(d) Appearance of the UretJira in Disease. — The 
shape and size of the fiannel will be modified variously, 
depending upon the nature and extent of the infiltration 
and thickening present in the urethral walls. If the 
mucous membrane is oedematous, the natural folds will 
be increased in size and will come together nearer the 
end of the tube, forming a short, narrow funnel ; or if 
this swelling be soft and considerable, the membrane 
will bulge into the end of the tube. In this condition 
the folds and the funnel re-form rapidly after moving the 
tube. If there be firmer and deeper infiltration of the 
tissues than in the condition just described, the walls of 
the urethra will not come together so readily, the funnel is 
longer and larger and more rigid, and the changes occur 
slowly. In either form of infiltration and swelling, if the 
process be unilateral, unequal, or irregular, the funnel 
will be unsymmetrical, the central figure will be variously 
distorted, and irregular folds may bulge into the tube. 



CHRONIC URETHRITIS. 507 

While pathological changes in the deeper tissues can 
thus be recognized, the endoscope is chiefly valuable 
in demonstrating and treating lesions on the surface of 
the mucous membrane. The color of small or even 
large areas may be changed from the normal pink to a 
bright red or to some of the darker, duller shades of 
bluish and brownish red or purple; or, on the contrary, 
it may be almost white. The normal dull lustre may be 
lost, and the surface may appear smooth and shining or 
even glistening, or rough, dull, and cloudy. Losses of 
epithelium give the surface a finely stippled appearance. 
Areas of granulation are of frequent occurrence and are 
readily recognized. Morgagni's lacunae are often in- 
volved in chronic urethritis, and appear as circumscribed 
reddened and swollen areas, or as sharply defined pin- 
head-sized or larger pits or depressions. Small areas of 
superficial ulceration may be found. These areas are 
very sensitive, may appear depressed, and lack the 
smoothness and lustre of the normal membrane. Occa- 
sionally tumors may be present in the urethra and be 
the cause of slight persistent discharge or disturbances 
in urination. These tumors are recognized by the en- 
doscope in the form of smooth polypi or more frequently 
as small warts or papillomatous growths. The latter are 
usually situated near the meatus. 

The above-described pathological changes are found 
chiefly in the bulbous and pendulous portions of the 
urethra. In the pars posterior they are found less fre- 
quently and are not so well understood. Endoscopic 
examination of this region is not often called for, though 
it is occasionally of great service in both diagnosis and 
treatment. The straight tube does not readily enter the 
prostatic urethra without the application of some force, 



k 



508 SYPHILIS AND THE VENEREAL DISEASES. 

and the resulting hemorrhage not infrequently is suffi- 
cient to prevent an accurate inspection of these parts. 

Treatment of Chronic Urethritis. — It is difficult to 
lay down definite rules for the management of chronic 
urethritis, since so much depends on the individual, his 
habits and surroundings, and on the duration, character, 
and previous treatment of his disease. Frequently the 
condition of the patient, more than that of his urethra, 
should be considered. In cachectic individuals local 
treatment of the urethritis may accomplish little as com- 
pared with properly directed constitutional treatment. 
In cases of simple anemia, debility, or exhaustion, rest 
and proper tonics will often be more effective in caus- 
ing the disappearance of a urethral discharge than will 
any amount of local treatment. In men who have been 
violating the laws of sexual and general hygiene, chang- 
ing the habits of living to conform with these law^s may 
make other treatment unnecessary, and until such changes 
are made local treatment will do little, if any, good. 

The hygiene of chronic urethritis is practically that of 
the acute disease, except that greater freedom is allowed 
the patient in matters of diet and exercise. Tobacco, 
alcohol, and rich or highly seasoned foods should be inter- 
dicted ; sexual excitement and unrest should be avoided. 
For the unmarried man absolute continence, both mental 
and physical, is the only course. In married men moder- 
ate, unstimulated sexual relations are permissible, or even 
beneficial, in cases of slight, persistent discharges which 
the physician is satisfied are non-infectious. In the case 
of the unmarried man who has been tormenting both 
mind and body in his ceaseless efforts to remove the last 
traces of a catarrhal discharge from the urethra and to pre- 
pare himself for matrimony, and whose morbid mental 



CHRONIC URETHRITIS. 509 

condition interferes with sexual hygiene by keeping the 
organs in a state of unrest, marriage is the best remedy. 
Keyes says: "A regular, moderate exercise of the sexual 
organs tends surely to keep down congestion and to 
allow that rest which is most important in effecting a 
cure." It is needless to add that such exercise of the 
sexual organs cannot be found outside of the married 
state ; and, furthermore, the mental and moral influence 
upon such a man of his marriage to a pure-minded 
woman is a large — frequently the most important — 
factor in effecting his recovery. In such cases the 
physician will not, of course, recommend marriage until 
he is satisfied that the urethral discharge is non-infec- 
tious and that the man is resolutely endeavoring to live 
according to the laws of sexual hygiene. 

The use in the urethra of strong injections, of bulbous 
sounds, of dilating instruments, or of the endoscope 
necessarily irritates the otherwise healthy portions of the 
mucous membrane, causing temporary inflammation of 
these areas. Even mild injections and the blunt steel 
sound are slightly irritating to the normal mucous mem- 
brane, and their use is followed by some hypersecretion 
of mucus. Hence the folly of continuing local treatment 
indefinitely in hope of removing the last drop of mucus 
which appears at the meatus, and hence the impossibility 
of making an accurate diagnosis in a case of urethritis 
that is being treated locally. 

In undertaking the management of a case of chronic 
urethritis that has been under more or less constant local 
treatment, it is always advisable to give the urethra a 
rest for several weeks before again beginning topical ap- 
plications. This rest gives the mucous membrane a 
chance to recover from the irritation produced by local 



510 SYPHILIS AND THE VENEREAL DISEASES. 

interference, and allows the surgeon at the end of this 
time to determine with greater accuracy the nature of 
the organic lesions that may be present. It also happens 
that the same local treatment which was ineffective when 
pursued constantly will, after such a rest, be followed by 
prompt and beneficial results. In cases in which no or- 
ganic lesions are present, cessation of local treatment for 
a few weeks may result in complete disappearance of the 
urethritis. Such cases are more numerous than the ma- 
jority of practitioners are willing to believe. Many of the 
so-called " incurable " cases of chronic urethritis, which 
refuse to yield after months or years of treatment, need 
only rest and hygiene to bring about their recoveiy. In 
stopping all local treatment it may be well at first to give 
small doses of sandalwood or of cubebs. The urine 
should be kept unirritating at all times. 

For purposes of treatment all cases of chronic ure- 
thritis may roughly be divided into two classes. The first 
class includes those cases in which a considerable por- 
tion or all of the urethral mucous membrane is involved 
to a greater or lesser degree. This condition is found 
in cases following a recent gonorrhoea, in relapses and 
exacerbations of chronic urethritis, in urethras subjected 
to constant or excessive local treatment, and in the chron- 
ic urethritis of men who are cachectic or who are not 
living hygienically. The amount of secretion in these 
cases may be considerable, and may vary from a mere 
hypersecretion of mucus to a more or less .purulent dis- 
charge resulting from a true inflammation of the mem- 
brane. If posterior urethritis be present, the second 
portion of the urine will be cloudy. The second class 
includes those forms of urethritis in which the larger 
portion of the urethral mucous membrane has returned 



CHRONIC URETHRITIS. 511 

to its normal condition, the pathological process being 
limited to one or more circumscribed areas. The secre- 
tion in these cases is slight, and may not be apparent 
except as shreds in the urine. It is evident that a case 
of the second may temporarily be transformed into one 
of the first class, as a result of sexual or other excesses 
or of active local treatment. 

Treatment of Cases of the First Class. — In these cases 
the discharge, the pus in the urine, or the subjective 
symptoms show that a considerable portion of the ure- 
thral mucous membrane is inflamed, or at least irritated 
and congested, and that all instrumentation of the ure- 
thra should be avoided. The treatment should corre- 
spond with that given for the late stages of gonorrhoea. 
Internally, sandalwood and cubebs give good results, 
though copaiba is indicated if the symptoms become at 
all acute. In posterior urethritis boric acid is of special 
value, and may be given in addition to one or more of 
the above-named remedies. Local treatment should be 
limited to the use of injections or irrigations. 

The injections used may be those recommended for the 
declining stages of gonorrhoea, though it may be necessary 
gradually to increase their strength. Many other prepa- 
rations are recommended, and sometimes prove service- 
able in the treatment of chronic urethritis. Among 
them are nitrate of silver, sulphate of copper, and chlo- 
ride of zinc. Each of these may be used in strengths 
varying from one-fourth of a grain to a grain in an ounce 
of distilled water. Alcohol or glycerin, or both, may be 
added to any of these preparations, the quantity added 
being small at first and gradually being increased if it 
does not irritate the urethra. Instead of alcohol an 
astringent wine may be used. The practitioner is again 



k 



512 SYPHILIS AND THE VENEREAL DISEASES. 

warned against the folly of using too many injections. 
He will obtain the best results if he limits himself to 
two or three preparations with which he has become 
thoroughly familiar. He can easily vary their strength 
and frequency of application to suit the needs of each 
case. Strong injections should not be used until weaker 
ones, after faithful trial, fail to do good. The solutions 
used should always be weak at first, and if necessary 
gradually be increased in strength, and injections strong 
enough to produce decided burning or smarting sensa- 
tions in the urethra should not be used. 

It should be remembered that often the last drop of 
mucus will not disappear from the meatus until after the 
injection has been stopped and the mucous membrane has 
had time to recover from the stimulating effects of local 
treatment. If, after using an injection for two or three 
weeks, the discharge is reduced to a drop or two, the 
injection should be used with gradually diminishing fre- 
quency for a week or two and then be stopped, and the 
patient should be allowed a fortnight without local treat- 
ment. If the slight discharge or the shreds in the urine 
persist, the case is, so far as the anterior urethra is con- 
cerned, one of the second class, and is ready for exam- 
ination and treatment with instruments. 

Injections made with a gonorrhceal syringe will, of 
course, reach only the anterior urethra. If posterior 
urethritis be present in such degree that the second 
glass of urine is clouded with pus, the inflammation 
should be reduced as far as possible before beginning 
the use of sounds and instruments. This result can 
usually be accomplished by means of internal treat- 
ment, aided, in some cases, by deep irrigation. A 
number of methods of irrigating the deep urethra have 



CHRONIC URETHRITIS. 513 

been advocated, and several instruments have been de- 
vised for the purpose, but all the apparatus necessary 
is a short glass or rubber tube — or, if preferred, a soft 
catheter — connected by means of rubber tubing with the 
reservoir containing the solution to be used. The reser- 
voir, filled with the warmed solution, is held about two 
feet above the level of the penis, and, after allowing the 
liquid to flow long enough to expel the air from the tub- 
ing, the nozzle is inserted for a short distance within the 
meatus and is held there loosely, permitting a free out- 
flow of the solution. The anterior urethra is thus cleansed, 
and pus or shreds that have been present in this portion 
will not be carried into the pars posterior during the 
subsequent steps of the operation. When the solu- 
tion coming from the urethra is clear and free from 
shreds, the lips of the meatus may be gently closed upon 
the tube and the reservoir slowly and gradually elevated 
until the pressure thus acquired overcomes the com- 
pressor urethrae muscle, and the fluid passes over the 
mucous membrane of the deep urethra into the bladder. 
Instead of a short tube a soft catheter may be used. 
After washing out the anterior urethra the tip of the 
catheter may be passed to the membranous or the begin- 
ning of the prostatic urethra ; the fluid will then fill the 
deep urethra and pass into the bladder. The point is 
known to have entered the membranous portion by the 
yielding of the compressor urethrse muscle, which can 
generally be recognized by the operator, or by the fact 
that the fluid no longer escapes from the meatus ; or the 
catheter may be passed into the bladder and slowly with- 
drawn until the urine ceases to flow, and the tip is thus 
known to be in the deepest portion of the prostatic ure- 
thra. The catheter should be lubricated with glycerin, 

33 



514 SYPHILIS AND THE VENEREAL DISEASES. 

since oil or vaseline would coat the mucous membrane 
and interfere with the action of the solution. 

Finger has devised an ingenious apparatus by means 
of which he varies the pressure of the liquid in the 
urethra without varying the elevation of the reservoir. 
The apparatus is practically a very large barrel-syringe 
fastened vertically against the wall. The lower end 
is provided with a rubber tube, a yard or more in length, 
terminating in a short pear-shaped nozzle fitted with a 
stopcock. The upper end of the barrel is simply a 
loose-fitting cover perforated by the piston-rod. To 
obtain a minimum pressure both cover and piston may 
readily be removed ; to obtain greater pressure the piston 
is allowed to rest on the surface of the liquid in the 
barrel, and weights are placed on a disk fastened for this 
purpose to the upper end of the piston-rod. Ultzmann's 
instrument is an excellent one, but with the metal catheter 
which he employs there is greater danger of damaging 
the inflamed mucous membrane than with the soft 
catheter. 

Of the many solutions used for irrigation of the deep 
urethra, the following are among the best : Nitrate of 
silver (i : 20,000 to i : 500 of distilled water), bichloride 
of mercury (i : 80,000 to i : 10,000), sulphate or acetate 
of zinc (i : 1000 to I : lOo), and permanganate of potash 
(i : 20,000 to I : 1000). Ultzmann's method was as 
follows: There was prepared a solution containing 
I part each of crude alum, zinc sulphate, and carbohc 
acid in 500 parts of water. For the first irrigation 
this solution was diluted with three times its bulk 
of warm water. If well borne, the strength was 
gradually increased until at the end of three or four 
days or a week the solution was used in full strength. 



CHRONIC URETHRITIS. 515 

This preparation was then changed for a solution of 
permanganate of potash, i : 20,000, gradually increased 
in strength up to i : 1000. Lastly, a solution of 
nitrate of silver, i : 2000, was substituted, and was 
gradually increased in strength to i : lOOO. Irrigations 
were given daily. 

As with injections, weaker solutions should be tried 
first, and the strength gradually be increased when 
necessary and when the resulting irritation of the 
urethra is slight. They may be used at first about 
once in three days, but w^hen the urethra becomes ac- 
customed to the process and shows a milder reaction 
after it, they may be given every other day or even daily. 
At each irrigation about 4 ounces of the warmed solu- 
tion should be used in the posterior urethra, after 
the anterior urethra has been cleansed thoroughly. 
The bladder should be about half full, that the urine 
may dilute the solution sufficiently to prevent injury 
to the bladder-walls. It is desirable to have the patient 
retain his urine for some time after the irrigation, that 
the medicament may be left as long as possible in 
contact with the mucous membrane of the urethra. 

In case both anterior and posterior urethritis are 
present, and irrigation is practised every second or 
third day, the patient may use an injection once or 
twice a day. If after two or three weeks of such 
treatment the subjective symptoms disappear, the dis- 
charge is reduced to a drop or two of mucus, and the 
urine is clear but for a few shreds, the irrigations 
and injections should be given at gradually increasing 
intervals for a week or more, and then be stopped en- 
tirely. A week or two of rest from local treatment may 
remove these last traces of the disorder ; if, however, 



5l6 SYPHILIS AND THE VENEREAL DISEASES. 

they persist, the case may be considered one of the 
second class, and treatment v/ith instruments is then 
proper. 

Tjratinent of Cases of the Second Class. — In these 
cases the subjective symptoms, the discharge from the 
meatus, and the cloudiness of the urine are slight but 
persistent, and are usually due to local lesions. In a 
large proportion of cases stricture in some form or 
degree will be found, and is the most important and first 
lesion to be treated. In the absence of stricture there 
may be congested or infiltrated and thickened patches 
of mucous membrane or of submucous tissue. There 
may be inflamed follicles and lacunae, or small areas of 
granulations, or superficial losses of tissue. When these 
conditions exist, they should be sought for and located 
by means of the steel sound, the bulbous bougie, or the 
urethrometer. In some cases of the torpid and persist- 
ent type no local lesions can be found, but there may 
be, instead, an atonic and mild catarrhal condition of a 
considerable portion of the membrane. 

In almost all cases of chronic urethritis of the second 
class the most effective local treatment is found in the 
proper use of the steel sound. The dilation of the 
urethra by the full-sized steel sound opens and smooths 
out the folds and lacunae of the mucous membrane, thus 
freeing them of retained secretions which the stream of 
urine does not reach. The pressure exerted by the 
sound empties inflamed follicles of their contents and 
stimulates the process of absorption in the areas of con- 
gestion and thickening, while the effect of the cold steel 
upon granulating patches and upon an atonic, catarrhal 
condition of the mucous membrane is stimulating and 
often beneficial. The best instrument to use is a 



CHRONIC URETHRITIS. 517 

smooth, blunt steel sound of the largest size that will 
pass the meatus without stretching it. It is not neces- 
sary, as a rule, to cut the meatus unless the latter be 
abnormally small. If this be the case, the narrowing is 
usually due to a thin band of tissue at the lower end of 
the aperture ; behind the band is a small pouch that 
can be detected by the point of a probe introduced into 
the urethra for half an inch and drawn forward along the 
floor. This condition may be the sole cause of the per- 
sistence of a discharge, since it interferes with the free 
drainage of the urethra. In this case all that is neces- 
sary is simple incision of the thin band of tissue, fol- 
lowed by the use of sounds for a few days to keep the 
cut edges from reuniting. 

Any incision of the meatus should be made down- 
ward in the median line, and not upward, and should 
be done slowly and with great care, not with a single 
stroke. Since the meatus is often normally the nar- 
rowest point of the urethra, it is sometimes necessary 
to enlarge it in order to introduce larger instru- 
ments for the treatment of the deeper parts. But this 
little operation, simple as it is, leaves the meatus in 
a condition not natural to it, and therefore cannot be 
entirely harmless. The physician who treats many 
obstinate cases of chronic urethritis will see a proportion 
of them in which the lips of a freely cut meatus gape 
widely and expose a considerable portion of urethral 
membrane which under normal conditions would be 
covered and protected. In this condition may be found 
the cause of not a few persistent urethral discharges. 
The surgeon w4io recognizes these facts will not look 
upon the mutilation of the meatus as a simple and 
harmless procedure, to be adopted as a matter of con- 



5l8 SYPHILIS AND THE VENEREAL DISEASES. 

venience, but will reserve the operation for those cases 
in which the meatus is abnormally small, or in which 
the condition of deeper portions of the urethra necessi- 
tates the use of instruments too large to pass the normal 
meatus. 

Before introducing the sound it should be oiled, but 
not warmed. It should be introduced with great gentle- 
ness, allowed to remain from a few seconds to fifteen 
minutes, and as gently withdrawn. If the lesions to be 
treated are in the posterior urethra, the tip of the sound 
will be carried on into the bladder. It is rarely neces- 
sary to use a sound in this region more frequently than 
once in three days. If the lesions are limited to the 
pars anterior, the sound should not be passed further 
than necessary to affect the lesions, and a short, blunt 
sound is often more convenient than a curved one. 
Usually there is little gained in passing sounds oftener 
than once in three days, though they may be used more 
frequently in the pars anterior. 

The use of the cold sound is especially valuable 
in disease of the pars posterior complicated by chronic 
prostatitis, prostatorrhoea, or sexual neurasthenia. In 
these cases the sound may be introduced as often as 
every second day, providing the irritation or reaction 
resulting from its passage subsides within a few hours; 
and when the urethra tolerates well the presence of 
the sound, it may be held in position from a few 
seconds to fifteen minutes before withdrawing. In 
place of the ordinary sound the cold sound of 
Winternitz (Fig. 23) may be used. This instrument 
is a metal catheter closed at its vesical end and 
divided into two channels by a longitudinal septum. 
Just within the tip the two channels communicate, while 



CHR ONIC URE THRI T7S. 5 I 9 

externally they connect in a fork-shaped end with two 
rubber tubes. Water injected into one tube flows out 
of the other after passing through the entire length of 





Fig. 23. — Winternitz's psychrophor (cooling sound). 

the catheter twice. If the end of one tube be immersed 
in water and suction be made upon the other end, the 
water will flow through the catheter as in a siphon. It 
is well to begin with water at the temperature of the 
room, and to cool it gradually until eventually ice-water 
may be used. The application should last from five to 
fifteen minutes, and may be given about every second 
day. 

Another method of treating disease of the pars pos- 
terior, highly recommended by Keyes and others, lies 





Fig. 24. — Keyes-Ultzmann syringe (Tiemann). 

in the use of deep injections. The best instrument for 
the purpose is Keyes' modification of Ultzmann's deep 
urethral injector (Fig. 24). The tube of the catheter is 
capillary in size and open at the end. Before introduc- 
ing the instrument the catheter is completely filled with 



520 SYPHILIS AND THE VENEREAL DISEASES. 

the liquid, so that for every drop forced out of the barrel 
of the syringe an equal drop escapes from the tip. The 
lesion to be treated having been located, the tip of the 
syringe is carried to this point, and from 3 to lo minims 
of the solution are deposited upon it. The best prepa- 
ration for this use is a solution of nitrate of silver vary- 
ing in strength from i grain to \ drachm (in rare cases 
gr. xlv) to the ounce. This cauterizing or " etching " 
of the deep urethra is followed by a more or less violent 
reaction. The desire to urinate is felt almost immedi- 
ately, and for a few hours tenesmus and other painful 
symptoms may be present. The application should not 
be repeated oftener than two or three times a week, and 
never before the irritating effects of the previous applica- 
tion have entirely disappeared. Solutions of this strength 
should not be injected into any portion of the anterior 
urethra, hence the operator must know that the tip of 
the catheter has at least entered the membranous por- 
tion. With the finger in the rectum, exact location of 
the tip should not be difficult to one familiar with the 
use of sounds. If in any case the operator is in doubt, 
he can satisfy himself by detaching the syringe from the 
catheter and using the latter in the manner described for 
deep irrigation : urine escapes, if the bladder be full, when 
the tip of the catheter enters the neck of the bladder. 

Finger and others recommend the introduction of 
lanolin instead of watery solutions, and Tommasoli 
devised a syringe for the purpose. The piston within 
the catheter is on a flexible rod marked in decigrams, 
so that the amount of the application can be regulated 
with accuracy. One decigram of the following solu- 
tion may be placed in the deep urethra at each treat- 
ment: 



CHRONIC URETHRITIS. 52 I 



^. Argent, nitrat, 


gr. XV-3J ; 


Lanolini, 


5iij ; 


01. olivar., 


3iss. — M. 



Sulphate of copper or creolin may be substituted for 
the nitrate of silver in this ointment. Regarding this 
form of medication Finger says : " The lanolin ointments 
possess the advantage of adhering intimately to the 
mucous membrane. If fluids, gelatin, or cacao-butter 
bougies are introduced, they are washed out of the 
urethra by the first micturition. On the contrary, the 
contracting urethral walls compress the lanolin ointment 
after the injection and press it into the mucous mem- 
brane. Micturition evacuates only small particles of 
the ointment ; these particles are found in the urine even 
thirty-six hours after injection. Even pollutions do not 
remove all the ointment from the urethra. It therefore 
forms a real urethral bandage, and its protracted action 
and gradual absorption have a more favorable effect 
than the ephemerally acting solutions. In addition, as 
Professor Liebreich kindly informs me, lanolin is an 
aseptic substance." 

The deep injection of an aqueous solution or a lanolin 
ointment immediately after using the cold sound is 
sometimes followed by excellent results. Finger rec- 
ommends this combined treatment in old foci of infil- 
tration in the pars posterior and in the bulb. For this 
purpose he uses the following ointment : 

!^. Potass, iodid., Siss ; 

lodin. puri, gr. xv ; 

Lanolini, ^iij ; 

01. olivar., Siss, — M. 



522 SYPHILIS AND THE VENEREAL DISEASES. 

Other methods of medicating the deep urethra have 
been tried. Among those still in use are soluble 
bougies, ointments introduced on grooved sounds, and 
the injection of finely divided solids suspended in a 
sticky fluid. These methods are not so serviceable as 
those already given, and are rapidly falling into disfavor. 

Finally, by means of the endoscope granulating 
patches, superficial ulcers, areas of congestion, inflamed 
follicles, and foreign growths in the urethra may be 
brought into view, and applications may be made 
directly to them. The most useful preparation is 
nitrate of silver in solution varying from i to 20 per 
cent., though it may occasionally be used much 
stronger. Sulphate of copper may be used in the same 
manner. Lugol's solution and other preparations of 
iodine, as well as carbolic acid in varying strengths, 
alone or combined with iodine and glycerin, are ser- 
viceable at times. Any of the above drugs may be 
applied in the form of lanolin ointment, and iodoform, 
iodol, aristol, or other powders may be used. For the 
application of solutions or ointments nothing is better 
than bits of cotton twisted on the ends of wires or on 
thin strips of wood such as may be obtained from 
match-factories. Ultzmann invented a brush apparatus 
for the purpose. The handle of the brush can readily 
be adjusted so that the brush will reach only that por- 
tion of membrane that projects beyond the rim of the 
endoscopic tube. After the use of strong solutions the 
surface should be dried of any surplus, to prevent its 
reaching other portions of the membrane ; to lessen 
pain, iodoform in powder or in ointment may be applied. 
Applications may be made from once in three or four 
days to once in a week or two, depending on the 



CHRONIC URETHRiriS. 523 

strength of the solutions used, the sensitiveness of the 
patient, and the amount of irritation that follows. 
When the condition begins to improve, the intervals 
between treatments should gradually be lengthened. 

In general, with reference to local treatment of ure- 
thritis, it should be remembered that the use of an injec- 
tion or an instrument in the urethra is followed by more 
or less reaction and irritation. The reaction may appear 
in the form of an increased discharge from the meatus, 
in case the pars anterior is alone affected, or in frequency 
of micturition and tenesmus when the pars posterior also 
has been treated. The symptoms usually appear at once, 
increase for a few hours, and then rapidly subside. Irri- 
gation, deep injection, or instrumentation of the urethra 
should not be repeated until all evidences of a reaction 
from the previous treatment have been absent for twenty- 
four hours. Rough treatment of the urethra is never 
permissible. All instruments should be used with great 
care and gentleness. Mild methods and preparations 
should always be used in beginning the management of 
any case. If these methods prove insufficient, more ener- 
getic measures may gradually be adopted. During local 
treatment the sensitiveness of the urethra becomes dulled, 
and good results follow the employment of remedies 
which, if used at first, would produce violent inflammation. 

As a rule, the first micturition which follows a local 
treatment of the urethra is attended by more or less 
smarting and burning, and, when possible, should be de- 
layed for a number of hours, for when urination follows 
too closely the use of instruments, the much-to-be-desired 
rest of the recently treated parts is prevented, and often 
the amount of irritation and reaction is increased ; after 
local applications the immediate passage of urine removes 



524 SYPHILIS AND THE VENEREAL DISEASES. 

some of the remedy and interferes with its action. In 
consequence, local treatment of the urethra should usually 
be preceded by evacuation of the bladder. The excep- 
tions to this rule are found in irrigation of the deep ure- 
thra, for which the bladder should contain half a pint or 
more of urine, and occasionally in beginning the use of 
deep injections, when the immediate passage of urine 
may be desired to lessen the action of a remedy whose 
effect threatens to be too severe. 

If improvement follows a certain treatment, it should 
be given with gradually diminishing frequency, and should 
finally be suspended. Its best effects will not be appar- 
ent until after the urethra has rested for a couple of weeks 
or more. If a given treatment fails to do good, it is 
usually best to follow it with a period of rest before try- 
ing anything else. 

Finally, while studying and making intelligent appli- 
cation of local measures the successful physician will not 
fail to keep a constant watch over his patient's general 
health, habits, and surroundings. 

Prognosis. — It is evident that in chronic urethritis a 
guarded prognosis is necessary, and many factors must 
be considered. 

In the tubercular, cachectic, or anaemic, the future of 
the urethritis depends largely on the future health of the 
individual. 

In a man who is violating the laws of sexual and gen- 
eral hygiene the future course of urethritis will depend 
chiefly upon the promptness and completeness with 
which he changes his mode of living to conform to these 
laws. 

Recent cases that have received little treatment recover 
more promptly and certainly than do older cases. Old 



CHRONIC URETHRITIS. 525 

cases that have been subjected to more or less constant 
and severe forms of treatment are among the most in- 
tractable. Such urethras can never return fully to their 
virgin condition, and such portions as have been destroyed 
by cutting or cauterizing can never be replaced by nor- 
mal tissue. It may therefore be impossible to remove 
entirely the few shreds in the urine, the drop of mucus 
at the meatus, or the sensitiveness of the prostatic ure- 
thra that necessitates slight increase over the normal in 
the frequency of urination, though in all other respects 
recovery may be complete. 

Disease of the pars anterior can usually be cured, while 
lesions that persist cause no serious symptoms, if excep- 
tion be made of the extensive and deforming cicatrices 
which sometimes follow ill-advised operations. 

Disease of the pars posterior is less accessible to treat- 
ment, and if complicated by prostatitis and neurasthenic 
symptoms the prognosis is less favorable. Some patients 
for weeks or months — even for years — after all evidences 
of organic lesions have disappeared will complain of 
vague, ill-defined, or even neuralgic pains and other un- 
comfortable sensations in the perineum, in the testicles, 
or in the end of the penis, together with a frequent de- 
sire to urinate, hypersesthesia of the urethra, and irrita- 
bility of the sexual organs. These symptoms usually 
vary with the general nervous condition of the patient, 
and with time, patience, and proper management (chiefly 
hygienic) most of the cases recover. 

If stricture be the cause of a urethritis, the prognosis 
of the latter will depend on the nature and location of 
the former. 

The contagious element in most, if not in all, cases of 
chronic urethritis may be removed. 



STRICTURE OF THE URETHRA. 



Stricture of the urethra has been defined commonly 
as an unnatural narrowing or constriction of some por- 
tion of the urethral canal. As the urethral walls are 
usually in apposition, and the urethra is a canal only 
when distended with fluids or instruments, stricture has 
been defined as a loss of dilatability of the urethra. 
These definitions include a number of conditions, which, 
for the sake of clearness, are given brief mention before 
beginning the consideration of the subject in hand — 
namely, true organic stricture. 

The calibre of the urethra may be narrowed, even to 
the point of complete obstruction, by pressure from with- 
out of a periurethral abscess, cyst, or other tumor, or of 
an inflamed or hypertrophied prostate; or by the pres- 
ence within the urethra of polypi or other growths ; but 
in these conditions the narrowing is secondary to other 
diseases, and, to avoid confusion of terms, should not be 
called " stricture." 

The swelling of the mucous membrane in acute in- 
flammation of the urethra may diminish the size of the 
canal sufficiently to interfere greatly with the passage 
of urine, but this condition, unless complicating a pre- 
existing organic stricture, or unless associated with pros- 
tatic disease or urethral spasm, is never sufficient to 
cause complete retention, and, moreover, is transitory. 
The term " inflammatory stricture," which has been 

52 f) 



STRICTURE OF THE URETHRA. 527 

applied to this condition, is confusing and should be 
dropped. 

Spasmodic stricture is a term applied to the spas- 
modic contraction of the urethral muscles that frequently 
occurs during- instrumentation of the urethra, and which 
not uncommonly results from other local or reflex irrita- 
tion or from psychical causes. In the majority of 
healthy urethras the passage of a bulbous bougie for the 
first time will induce a contraction of the urethal muscles 
sufficient to impede the progress of the instrument for a 
few seconds. Spasmodic contraction of the compressor 
urethrse and the " cut-off" muscles, or the failure to in- 
hibit such contraction, makes it impossible for some men 
to urinate in the presence of others. In such a case the 
urethra and bladder may be entirely normal, and the 
cause of the failure is purely mental, for if the patient 
withdraw to a private closet, or if a catheter be passed 
beyond the contracted muscle, the urine flows freely. 

While urethral spasm may thus occur in apparently 
healthy individuals with normal urethras, its production 
is usually due to some local or general pathological con- 
dition. Predisposing causes are found in a sensitive or 
irritable condition of the nervous system, in any dis- 
turbed mental state, in cachexia and debility, and in a 
rheumatic or gouty diathesis. It is easily provoked in 
the intemperate, and especially in those whose sexual 
hygiene is faulty. In some individuals there is a local 
hyperaesthesia of the urethral mucous membrane for 
which no sufficient cause is found, but in whom intro- 
duction of a sound always produces urethral spasm. 

The exciting causes are found in any direct irritation, 
congestion, or inflammation of the urethra; in the reflex 
irritation due to disease of or operation upon any por- 



528 SYPHILIS AND THE VENEREAL DISEASES. 

tion of the genito-urinary tract, rectum, or anus ; in irri- 
tation reflected from more distant parts of the body; and 
in psychical disturbances. The use of instruments in 
the urethra or operations upon any portion of it may be 
followed by spasm of the deep urethra and retention of 
urine. Such spasmodic stricture may persist for several 
days. A similar condition frequently accompanies the 
congestion of the deep urethra resulting from alcoholic 
or sexual excesses or from exposure to cold. Occasion- 
ally such congestion and spasm are produced by the 
internal use of cantharides, turpentine, and other drugs. 
Reflex spasm of the deep urethra may follow operations 
upon, or disease of. any portion of the genito-urinary 
tract, or may result from inflamed hemorrhoids and 
other sources of irritation in the rectum. It is reported 
to have followed operations upon more distant parts of 
the body, and to have been produced by a number of 
other causes, including strongly concentrated urine, ma- 
laria, neuralgia, abscess of the lumbar vertebra (Keyes), 
necrosis of the coccyx (Emmet), etc. 

In most cases of urethral spasm, however, the cause 
lies in a congested or granular patch of mucous mem- 
brane or in an organic stricture situated in the bulbous 
or bulbo-membranous portion of the urethra. Spasmodic 
stricture may be produced by local disease in other por- 
tions of the urethra, if such lesions be irritated in any 
manner. The importance of a small meatus or of a 
stricture of large calibre in the anterior urethra as a 
cause of spasm of the deep urethra has unquestionably 
been over-estimated. Spasmodic stricture due to a con- 
genitally narrow meatus or to strictures of large calibre 
in the anterior urethra, uncomplicated by inflammation 
or other pathological changes, is certainly very rare. 



STRICTURE OF THE URE77IRA. 529 

Spasmodic stricture, which is usually situated in the 
membranous urethra, is due to the contraction of the 
compressor urethras and accelerator urinae muscles and 
of the voluntary perineal muscles which make up the 
"cut-off" muscles of Cruveilhier ; but it occurs in less 
pronounced form in the anterior urethra when the 
unstriped muscular fibres of the urethral wall contract 
about a foreign body — as an instrument — or about an 
irritated area of disease. 

The spasm of the urethral muscles that occurs during 
the passage of a steel sound is usually readily overcome 
by pressing the tip of the sound quietly and steadily 
against the contracted muscles for a few seconds. At 
the beginning of the membranous urethra, especially in 
a nervous or sensitive man whose urethra is being 
explored for the first time, the contraction of the 
muscles may be so firm and persistent that firm and 
steady but gentle pressure of the point of the sound 
will be resisted for several minutes before relaxation 
occurs and the instrument can pass. In such a case the 
relaxation is often sudden and pan be felt by the hand 
holding the sound, the tip of which passes the obstruc- 
tion with a slight jumping or jerking movement. As 
a rule, the largest blunt steel sound that a urethra can 
easily accommodate will overcome spasm better than 
a smaller one, and will often succeed when bulbous 
sounds or finer rubber bougies fail to pass. Hence, in 
the first examination of any urethra large sounds should 
be used. By beginning with smaller instruments, and 
especially with a bulbous sound, a diagnosis of organic 
stricture may be made when there is present nothing 
more than urethral spasm, which is readily overcome 
by the large blunt sound. 

34 



530 SYPHILIS AND THE VENEREAL DISEASES. 

In general, spasmodic stricture occurs suddenly and 
is paroxysmal, the stream of urine being normal in size 
except during the urethral spasm. If organic stricture 
is also present — and this is very frequently the case — 
its calibre will, of course, determine the usual size of 
the stream. Otis lays much stress upon the occasional 
occurrence of spasmodic stricture which may persist for 
years and in every way simulate organic stricture, even 
to resisting the passage of instruments in skilled hands. 
As every surgeon should make it a rule, before beginning 
a cutting operation on the deep urethra, to try to pass a 
sound when the patient is under an anaesthetic and the 
muscles are relaxed, these cases should always be rec- 
ognized in time to prevent a needless operation. In the 
exceptional cases which simulate organic stricture in 
yielding only to gradual dilatation, careful watching will 
sooner or later reveal the true condition, while the re- 
moval of the cause of the spasm will be followed by the 
disappearance of the supposed stricture. 

The treatment of spasmodic stricture lies in removing 
the cause when this can be discovered. Sexual and 
general hygiene and the general health of the patient 
should be properly regulated, a bland urine should be 
assured, and all sources of direct or reflex irritation, 
such as organic stricture and other lesions of the urethra 
or of other portions of the genito-urinary tract, should 
be removed. If retention occurs, it can usually be over- 
come by allowing the patient to recline in a hot bath 
until the muscles relax and the urine passes in the water. 
If this method fails, an opiate in full doses should be 
given, and, if necessary, a soft catheter may be passed 
after filling the urethra with warm oil ; this operation is 
rendered easier if done while the patient reclines in the 



STRICTURE OF THE URETHRA. 53 1 

bath. In extreme cases the production of full anaes- 
thesia may be required to cause relaxation of the spasm. 

Congenital stricture is rare and is limited to the 
meatus and the quarter of an inch of urethra immedi- 
ately posterior to it. The size of the normal meatus 
varies greatly in different individuals, and it is impossible 
to name a standard below which a meatus should be 
considered abnormally small. Keyes says : '' An indi- 
vidual with an average sized penis and urethra whose 
meatus will only take No. 10 (French) has stricture (con- 
genital) of the meatus, although he may never suffer 
any inconvenience therefrom." The opening may be 
no larger than a pin-head, and yet may cause the indi- 
vidual no inconvenience. Such a condition is in reality 
a slight deformity, and calls for no treatment. It is 
better to limit the term " stricture " to narrowings that 
are associated with pathological changes or that interfere 
with the normal functions of the urethra. 

If the normal urethra be distended to its greatest 
limit by means of the Otis urethrometer or of large 
bulbous bougies, in the large majority of cases the pen- 
dulous portion is found to be less distensible at some 
points than at others. These may be considered points 
of narrowing of the fully dilated urethra, but they are 
often inappropriately termed " strictures of large calibre," 
and as such are cut for the purpose of relieving deep 
urethral spasm and other functional genito-urinary dis- 
turbances for which the true causes are not appar- 
ent. These points of narrowing vary greatly in size, 
and are found chiefly within the first three inches from 
the meatus. As a result of many investigations both 
upon living and dead bodies, in which these points 
of contraction have been found in urethras otherwise 



532 SYPHILIS AND THE VENEREAL DISEASES. 

normal, the large majority of modern surgeons believe 
them to be physiological. They do not produce dis- 
turbances of the genito-urinary functions, and they do 
not interfere with the normal distention of the urethra 
during urination, or with the passage of ordinary sized 
instruments. Some practitioners are alone in working 
on the theory that the pendulous urethra should be a 
tube of uniform calibre — or, rather, of uniform disten- 
sibility — the diameter of which should bear a fixed rela- 
tion to the circumference of the flaccid penis. Other 
parts of the body are not constructed on such mathe- 
matical principles, and in the face of evidence to the 
contrary it is difficult to see why the penis should be 
considered an exception. 

In chronic urethritis these points of physiological 
narrowing in the pendulous urethra, as well as narrow- 
ings of the urethra due to chronic congestion and infil- 
tration of smaller or larger areas of the mucous membrane 
and the submucous tissues, have been subjects of much 
dispute. Some practitioners call such narrowings 
*' strictures of large calibre," and operate upon them for 
the sole purpose of relieving the urethral discharge. 
The majority of surgeons, however, do not consider such 
narrowings strictures, but treat them as cases of chronic 
urethritis. There are undoubtedly cases in which the 
question becomes a relative one, for the majority of stric- 
tures are preceded by chronic urethritis, with congestion, 
infiltration, and thickening of portions of the mucous 
membrane and the submucous tissues. Just when the 
formation of connective tissue begins in such areas, and 
just when contraction of such tissue is sufficient to inter- 
fere with the normal calibre of the urethra, are often dif- 
ficult questions to decide. It is best to class these nar- 



STRICTURE OF THE URETHRA. 533 

rowings with stricture only when there is periurethral or 
submucous deposit which has begun to contract and to 
diminish the lumen of the canal, producing a distinct 
contraction, or when symptoms of stricture (frequency 
of urination, dribbling of urine at the close of the act, 
gleet, etc.) are present. In a doubtful case, and es- 
pecially if the point of narrowing is covered by an in- 
flamed and thickened mucous membrane, it is better to 
postpone a diagnosis of stricture until the proper treat- 
ment for chronic urethritis — preferably the steel sound 
— has been given a faithful trial. 

The question as to what constitutes the normal calibre 
of any given urethra is considered more fully in the sec- 
tion on diagnosis, but, as a rule, if the penis be of average 
size and the urethra allows a No. 22 to 26 (French) steel 
sound to pass easily, the presence of stricture may be ex- 
cluded. Practitioners who find and cut numerous " stric- 
tures of large calibre " in the pendulous urethra claim 
that, though these narrowings be normal, in chronic 
urethritis they tend to increase the friction of urine and 
the irritation and inflammation at these points, and there- 
fore to favor a deposit of plastic material and the ultimate 
formation of a true stricture. It is undoubtedly true 
that such a result follows in a small number of cases, and 
that it could be prevented by early cutting, followed by 
the use of the sound ; but, on the other hand, it should be 
remembered that most of these cases recover under treat- 
ment (with the steel sound) given for chronic urethritis, 
and that cutting operations on the urethra, even in the 
most skilful hands, are attended by a mortality of from 
2 to 5 per cent. 



534 SYPHILIS AND THE VENEREAL DISEASES. 

ORGANIC STRICTURE OP THE URETHRA. 

Definition. — Organic stricture of the urethra may be 
defined as a pathological connective-tissue growth in the 
submucous and periurethral tissues, interfering with the 
normal calibre and the normal functions of the urethra. 
Dr. Bryson ^ calls attention to the fact that this connec- 
tive-tissue growth constituting stricture results from con- 
tinued pathological activity in the periurethral tissues and 
shows a distinct tendency to contract toward the axis of 
the canal. He proposes the name " chronic contracting 
periurethritis " by which to designate the " stricture 
disease." 

Stricture is most frequently found in men between the 
ages of twenty and forty-five. It is uncommon in 
women. 

Varieties of Stricture. — With reference to form, stric- 
tures are classed as (i) linear, (2) annular, and (3) tortu- 
ous. 

(i) Linear stricture is usually a cord-like band, such as 
would be produced by tying a cord about the urethra. 

(2) Annular stricture is a constriction such as would 
be formed by tying about the urethra a piece of tape not 
more than a quarter of an inch wide (Fig. 25). 

(3) Tortuous or irregular stricture includes every stric- 
ture that is wider than an annular stricture. It may be 
so extensive as to include the greater portion of the 
pendulous urethra. The calibre of this form of stricture 
usually varies in different parts, rendering the channel 
tortuous and irregular, hence the name (Fig. 26). 

Aside from the three forms of stricture described 
above, obstruction in the urethra may exist in the form 

^ Jotirna I of Cutaneous and Genito-urinary Diseases, Aug., 1 889. 



ORGANIC STRICTURE OF THE URETHRA. 



535 



of a thin membrane or diaphragm completely occluding 
the canal but for an opening situated centrally or eccen- 
trically ; or a crescentic or other shaped band or septum 
may project from a portion of the urethral wall; or there 
may be a number of fine bands crossing the urethra 




Fig 25. — Annular stricture (Dittel). 



obhquely or transversely, or so situated as to form flaps 
and valves. These finer bands, flaps, and valves are often 
the result of faulty instrumentation of the urethra. 

According to the amount of contraction present, stric- 
tures are usually divided into strictures of small calibre, 
which will only permit the passage of an instrument 
smaller than No. 1 5 (French), and strictures of large cali- 



536 SYPHILIS A.VD THE VENEREAL DISEASES. 

bre^ which will allow the passage of larger instruments. 
The division is an arbitrary one, but it is of practical 
value, since, as a rule, soft (flexible) instruments are to 
be preferred for all sizes below No. 15. The calibre of 
a stricture may become so narrowed that it will admit a 




Fig. 26. — Tortuous stricture, showing dilated Ibllicles, lacunae, and false passages 

(Dittel). 

fine probe with difficulty, but complete occlusion of the 
canal occurs only after traumatism or after some other 
outlet for the urine has been provided, as in the forma- 
tion of fistulse. 

According to their behavior with instruments, stric- 
tures are called irritable, when they are very sensitive 
and easily inflamed, or resilient, when they are elastic 



ORGANIC STRICTURE OF THE URETHRA. 537 

and after being dilated contract rapidly to their former, 
or even a smaller, calibre. 

Number of Strictures. — Strictures usually occur 
singly, but a urethra may contain several strictures. 
Thompson has never seen more than four in a single 
urethra. Other observers have reported larger num- 
bers. When a number of strictures are found in a single 
urethra, careful examination will usually determine them 
to be irregular contractions of one stricture. Multiple 
" strictures of large calibre " in the pendulous urethra are 
frequently reported by those who do not recognize the 
existence in this region of points of physiological nar- 
rowing. 

Location of Strictures. — The majority of strictures 
of the urethra are found in the region which includes 
the membranous and bulbous portions. The most 
common seat is the bulbous urethra. Stricture is fre- 
quently found within two and a half inches of the meatus, 
and is occasionally located in deeper portions of the 
pendulous urethra. Stricture does not occur in the 
prostatic portion. The majority of strictures occurring 
in the first two and a half inches of the urethra are found 
at the meatus or at the posterior limit of the fossa na- 
vicularis. The reason for the frequency of stricture in 
this region and in the bulb undoubtedly lies in the 
tendency of urethritis to become chronic in these parts 
— the result, probably, of their great vascularity and de- 
pendent position. The membranous urethra is more 
subject to traumatism than are the other portions, and 
is therefore the most frequent seat of stricture from this 
cause. 

Otis, working on the theory that the pendulous urethra 
should be a tube of uniform dilatability, finds the largest 



538 SYPHILIS AND THE VENEREAL DISEASES. 

number of strictures in this portion of the urethra, placing 
the majority within an inch and a half of the meatus, 

Etiolog'y. — Stricture of the urethra is probably always 
preceded by inflammation or traumatism of the mucous 
membrane, which is thus damaged sufficiently to allow 
the escape of smaller or larger quantities of urine into 
the submucous tissues. Any form of urethritis may 
be followed by stricture, but such records as have been 
collected indicate that at least 75 per cent, of all cases 
of stricture owe their origin to gonorrhoea. The more 
prolonged the inflammation, the greater the probability 
that stricture will follow ; and chronic urethritis which 
persists for months or years results in stricture in a 
large proportion of cases. If during a urethritis the 
inflammation extends to the periurethral tissues, the 
danger of stricture is greatly increased. The " break- 
ing " of chordee during gonorrhoea is certain to be 
followed by stricture of the worst type, since its origin 
is traumatic. Injections in gonorrhoea, when properly 
used, are not capable of producing stricture, but the 
careless use of a syringe with a long or rough nozzle 
can easily damage the mucous membrane near the 
meatus, and thus be the cause of stricture. This may 
be one of the reasons for the frequent occurrence of 
stricture in this region. If an injection (such as those 
used in attempts to abort gonorrhoea) be strong enough 
to excite an artificial urethritis or to destroy a portion 
of the mucous membrane, it will undoubtedly be fol- 
lowed by stricture. The formation of stricture as a 
result of urethral inflammation requires a number of 
months at least. Thompson reported, of 164 cases of 
stricture attributable to gonorrhoea, 10 that appeared 
soon after the attack, 71 within a year after its occur- 



ORGANIC STRICTURE OF THE URETHRA. 539 

rence, 63 in from three to eight years, and 20 in from 
eight to twenty-five years. Guyon and other observers 
have found that stricture appears from one to ten or 
fifteen years after gonorrhoea. When it occurs very 
early, it is probably due to traumatism. 

Traumatic stricture is most frequently found in the 
membranous urethra, where it follows blows upon the 
perineum, such as would be produced by a kick in this 
region or by a fall astride any hard substance such as a 
fence, a wheel, the tongue of a wagon, etc. If such an 
injury be violent and the injury to the urethra be con- 
siderable, it will immediately be followed by hemorrhage, 
and probably by retention due to inflammation and 
oedema of the urethral tissues. When the acute in- 
flammation subsides, repair of the tissues begins, result- 
ing in a cicatricial formation which ultimately contracts 
and produces stricture. In such cases the contraction 
is comparatively rapid and usually produces symptoms 
of stricture within a few months, though if the injury 
be limited to a portion of the urethral circumference 
cicatricial contraction may be slow and for several 
years may produce no evidence of stricture. If the 
first injury be slight, it may pass unnoticed and be for- 
gotten until symptoms of stricture appear some years 
afterward. 

In other portions of the urethra traumatic stricture 
may result from lacerations of the mucous membrane 
caused by the rough or prolonged use of instruments, 
or by the presence of other foreign bodies, such as 
sharp calculi, or from the breaking of chordee, or from 
other injury to the penis. Stricture may follow urethral 
chancre or other ulceration, or any process which 
destroys the mucous membrane of the part. It is 



540 SYPHILIS AND THE VENEREAL DISEASES. 

highly improbable that stricture ever results solely from 
masturbation, excessive coition, or prolonged erections, 
although, after stricture has begun to form, its further 
development is encouraged by any source of irritation, of 
congestion, or of inflammation of the urethra. Stricture 
also forms more readily in tuberculous or syphilitic 
individuals and in those of a rheumatic or gouty 
diathesis. 

Patholog-y. — Formation of Stricture. — According to 
Harrison's conclusions,^ which have been largely en- 
dorsed by other observers, the urethral epithelium is so 
damaged at one or more points, as a result of inflamma- 
tion or injury, that it permits the escape of minute 
quantities of urine into the submucous tissues. To 
prevent urine soaking further into the tissues, inflam- 
matory exudation is excited, and barriers of plastic 
lymph are thrown out opposite the places where leakage 
takes place. Such lymph ultimately organizes to form 
splints of connective tissue, evidently for the purpose of 
strengthening the urethral wall and preventing further 
leaking of the urine. But this connective tissue is 
apparently influenced in its growth by the presence of 
minute quantities of urine, and differs from similar 
tissue resulting from inflammatory exudates in other 
parts of the body in that it is denser and shows a more 
decided tendency to contract These characteristics are 
most marked in traumiatic stricture, in which the mucous 
membrane is lacerated and the urine escapes in larger 
quantities. In these cases the cicatrix is dense and 
contracted, and produces stricture of the worst type. 
Such stricture is frequently resilient. 

Tlie Lesion in Stricture. — The connective-tissue growth 

^ Lettso7)iian Lectures, 1888. 



ORGANIC STRICTURE OF THE URETHRA. 54 1 

constituting stricture may be limited to a very narrow 
line (linear stricture) in the submucous tissues, but it is 
usually formed in irregular masses in the submucous 
and periurethral tissues. It may include large portions 
of the corpus spongiosum and may obliterate its spaces 
(blood-cavities). The active development of the stric- 
ture-formation continues beneath the mucous membrane 
proper, which is thus pushed into the urethra in front 
of the new growth, and may show but little change in 
thickness or character even when the underlying stric- 
ture is bulky and nearly obliterates the urethral canal, 
though it may be thinned, atrophied, inflamed, ulcerated, 
or included in a cicatricial formation. In recent cases 
the tissue forming the stricture is small in amount and 
is comparatively soft and yielding. This tissue, how- 
ever, usually grows in density and in amount and con- 
tinues to contract. In old cases, when due to gonor- 
rhoea, the urethra may be surrounded at the site of the 
stricture by irregular areas of knobbed or corded, firm 
masses that can readily be felt by the fingers on the out- 
side of the penis as they follow the course of the ure- 
thra. The opening of the stricture is rarely situated 
centrally, but is most frequently found near the roof, as 
the stricture-formation is usually most abundant on the 
floor. The opening may be but slightly smaller than 
the normal calibre of the urethra, or it may become so 
small as to be almost impermeable. Complete occlusion 
is, however, rare except after severe injury to the ure- 
thra or after fistulae have formed to provide an escape 
for the urine. 

The rapidity with which stricture contracts and the 
density and extent of the connective tissue forming a 
stricture are dependent upon several factors. Strictures 



k 



542 SYPHILIS AND THE VENEREAL DISEASES. 

due to mechanical or chemical violence (traumatic stric- 
ture) contract earlier and are denser than those due to in- 
flammation. The amount and shape of the new formation 
in traumatic stricture depends largely upon the nature 
and site of the injury, and the stricture may be linear, an- 
nular, or irregular. Strictures due to gonorrhoea are often 
irregular in shape and lumpy. Cachexia and individual 
tendencies influence the development of stricture, which 
seems to form readily, extensively, and irregularly in 
the tuberculous or syphilitic or in those of gouty or 
rheumatic diathesis. The habits of an individual whose 
urethra contains a forming stricture also play an import- 
ant part; a faulty sexual hygiene, or anything that 
causes congestion of the urethra, will undoubtedly 
hasten the formation of stricture, and tend to make the 
latter dense and contractile. 

Changes in the Urethra. — As the stricture contracts 
and forms an obstruction to the free outflow of urine, 
each act of urination is accompanied by a dilatation of 
the urethra immediately back of the stricture. The fre- 
quent stretching of this part of the urethra is slight at 
first, but it gradually increases until the walls at this 
point lose their tone, become thinned, and a permanent 
pouch or sac is formed. This pouch retains constantly 
a drop or two of urine, which is decomposed by the 
mucus and acts as an irritant to the mucous membrane. 
Thus it happens that the urethral membrane immedi- 
ately back of a stricture is usually inflamed and produces 
a gleety discharge. The mouths of the ducts and folli- 
cles enlarge, and as the stricture contracts it increases 
during urination the pressure upon the urethral walls 
back of it. The mucous membrane in this situation be- 
comes more and more thinned and atrophied, and may 



ORGANIC STRICTURE OF THE URETHRA. 543 

be pushed out between the bands of muscular fibres to 
form saccuH or pockets in which a few drops of urine 
are retained and decomposed, thus adding to the in- 
flammation of the urethral wall, and therefore to the 
danger of ulceration. Such sacculi may have their 
origin in distended ducts or follicles. In severe cases 
ulcerations follow, allowing of the escape of a few drops 
of urine into the periurethral tissues. There are thus 
formed abscesses which open externally and result in 
urinary fistula. Occasionally some portion of the thinned 
urethral wall gives way, and urine in considerable quan- 
tity escapes into the surrounding tissues, producing the 
serious accident known as ''extravasation of urine." 

Resulting Changes in Bladder and Kidneys. — Early in 
stricture the congestion may extend to the neck of the 
bladder, causing vesical irritation with frequent micturi- 
tion ; or cystitis may result. Later, as the stricture con- 
tracts and produces greater obstruction to the outflow 
of urine, the detrusor urinae muscle, as a result of its 
efforts to empty the bladder, becomes hypertrophied and 
thickened, and bands of muscular tissue project into the 
bladder in ridges. The contraction of the hypertrophied 
muscles in the bladder-walls diminishes the size of the 
bladder-cavity and may eventually almost obliterate it, 
the muscles undergoing fibroid changes which render 
them incapable of distention. During the violent con- 
tractions of the bladder the weaker portions of the wall 
between the muscular ridges are pushed outward and 
stretched until finally they form sacculi or pouches 
which may have but a small opening connecting them 
with the proper bladder-cavity. These sacculi, having 
no muscular fibres in their walls, cannot empty them- 
selves ; they therefore retain the decomposing urine and 



544 SYPHILIS AND THE VENEREAL DISEASES. 

furnish a favorite site for the formation of calcuH. Rarely, 
as a result of rapid formation of stricture and over-disten- 
tion of the bladder, the bladder-walls, instead of becom- 
ing hypertrophied, are thinned and atrophied. Cystitis 
results in most cases in which decomposing urine is 
allowed to remain in the bladder. 

The pressure of the urine, especially during the act 
of micturition, extends backward through the ureters, 
which become dilated and hypertrophied, to the pelvis 
and to the calices of the kidneys, producing hydro- 
nephrosis. As a result of inflammation extending from 
the bladder through the ureters to the kidney, or more 
frequently as the result of microbic infection, there may 
follow pyelitis, pyelonephritis, or, rarely, abscess of the 
kidney and perinephritis. 

Symptoms and Results of Stricture. — The symp- 
toms produced directly by stricture are not so marked 
as are those resulting from secondary implication of 
other parts of the genito-urinary system. As these 
secondary symptoms or results of stricture may be first 
both in appearance and in importance, and as they are 
closely associated with such symptoms as may be due 
directly to the stricture-growth, it is best to consider 
them together. 

Stricture of large calibre may exist for months or even 
for years without producing symptoms of importance, 
though when the contracture of the urethra begins to 
interfere with the normal function of the canal, its pres- 
ence is usually manifested by a series of characteristic 
disturbances. 

Increased frequency of micturition is among the earliest 
symptoms of stricture, though it may be so slight at first 
as to pass unnoticed, or may be entirely absent. As a 



ORGANIC STRICTURE OF THE URETHRA. 545 

rule, the desire to urinate gradually becomes more fre- 
quent, until in old cases the patient may find it necessary 
to empty the bladder every few minutes. The frequency 
with which the bladder is evacuated in a day does not, 
however, necessarily indicate the degree of contraction of 
the stricture, but is largely dependent upon the tempera- 
ment of the individual and upon the presence or absence 
of cystitis and other complications. In the beginning this 
symptom maybe due solely to irritation reflected from the 
site of the stricture to the bladder, and later to irritation 
resulting from the increased efforts of the bladder to 
overcome the urethral obstruction and to empty itself. 
In many cases congestion of the vesical neck undoubt- 
edly occurs early, and, as the urethral inflammation back 
of the stricture increases, it extends at least to the deep 
urethra or to the neck of the bladder, resulting in a 
greatly increased frequency of micturition due directly 
to the posterior urethritis or cystitis. 

In tight stricture of long standing, as a result of which 
the bladder-walls have hypertrophied and so reduced 
the size of the cavity that it will hold but a small quan- 
tity of urine, the demands to urinate may be so frequent 
as to amount almost to incontinence. The same clinical 
condition is found with an atonic and constantly dis- 
tended bladder which has lost its power of complete 
contraction. Very late in the history of these cases the 
patient may be unable to retain his urine for even a short 
period, and it constantly dribbles from the urethra. In 
the first class of cases, in which the bladder-cavity is 
nearly obliterated, this condition constitutes true (and 
hopeless) incontinence, and should carefully be distin- 
guished from the mere overflow of a distended and 
atonic bladder. In the latter case the use of a catheter 
35 



54^ SYPHILIS AND THE VENEREAL DISEASES. 

will reveal the presence in the bladder of a large quantity 
of residual urine. A smaller amount of residual urine 
may be found in the majority of cases of organic stric- 
ture. In these two forms of bladder disease result- 
ing from stricture the frequency of micturition and the 
incontinence are worse during the day, due to the fact 
that when the patient assumes the upright position the 
urine in the bladder produces pressure upon the vesical 
neck, or, in case the latter is relaxed, upon the stricture 
and the dilated urethra back of it ; these same symp- 
toms, when due to prostatic disease, are usually most pro- 
nounced at night. 

Dribbling after urination is another early symptom of 
stricture. In a normal urethra the close of urination is 
followed by a wave of contraction of the muscular fibres 
surrounding the urethra, expelling the last drops of urine 
from the canal. This action is probably aided by a cor- 
responding wave of blood sent through the corpus spon- 
giosum by the contraction of the accelerator urinse mus- 
cle. The submucous deposit in stricture prevents, by 
its mere presence, the accurate closure of the urethra, 
and later, by invading the muscle-fibres themselves and 
by obliterating the meshes of the corpus spongiosum, 
may yet further interfere with the closure of the canal. 
In consequence, the last drops of urine are retained behind 
the stricture, and do not escape until later^ by force of 
gravity, when the penis is dependent. 

Urethral discharge, which, appearing as gleet or as 
shreds in the urine, is present in most cases of stricture, 
is produced by the urethral inflammation back of the 
constriction. In the forming stage of stricture the dis- 
charge may be furnished by the inflamed, granulated, or 
otherwise damaged urethral membrane beneath which 



ORGANIC STRICTURE OF THE URETHRA. 547 

stricture is forming. Opinions vary as to the constancy 
and importance of this symptom in its relation to stric- 
ture. Dr. White finds about 50 per cent, of strictures 
accompanied by a gleety discharge from the meatus, 
while a large majority of all others show shreds in the 
urine. Some observers maintain that the presence, for 
any considerable period, of a gleety discharge or of 
shreds and pus-corpuscles in the urine is sufficient evi- 
dence of stricture, and advise, in such cases, operation 
upon any points of narrowing, however slight, that can 
be detected in the urethra. That such a view is extreme 
and erroneous is evident, since many cases of chronic ure- 
thritis that have persisted for months or years recover 
completely under proper hygienic rnanagement and with- 
out local treatment. The amount of urethral discharge 
in stricture varies with the general condition of the 
patient and his habits of living. As in chronic ure- 
thritis, congestion or irritation of the urethra from any 
cause will increase the amount of the discharge. In 
stricture of large calibre the history and symptoms of 
the disease may differ in no particular from those of 
chronic urethritis. 

Retention of urme may occur early in stricture if the 
mucous membrane covering it becomes inflamed and 
swollen as a result of gonorrhceal infection, alcoholic or 
sexual excesses, cold, or other causes of urethral irrita- 
tion and congestion. Such retention, coming on sud- 
denly after a debauch, may be the first evidence of stric- 
ture recognized by the patient. This form of retention, 
due chiefly to urethral spasm and to swelling of the mu- 
cous membrane, rarely lasts more than a few hours, and 
is readily relieved by hot baths, an opiate, or the intro- 
duction of a soft catheter. In an unobserving or dis- 



548 SYPHILIS AND THE VENEREAL DISEASES. 

sipated patient other symptoms of stricture may pass 
unnoticed for months or even for a few years, and he may 
suffer from repeated attacks of sudden retention before 
applying for treatment. As the stricture contracts and 
diminishes the cahbre of the urethra, less and less swell- 
ing of the mucous membrane is required to produce 
retention, which consequently is more easily provoked, 
occurs more frequently, is more persistent, and is re- 
lieved with greater difficulty. In old cases sudden re- 
tention may necessitate the performance of perineal 
section under unfavorable circumstances. 

The stream of urhie becomes noticeably smaller only 
after the calibre of the urethra has been diminished con- 
siderably, as in health the size of the stream is much less 
than the urethral calibre (estimated by the size of the 
sound it will readily admit). As the stricture contracts, 
and especially if there be atony of the vesical walls, the 
patient finds he is unable to throw the stream of urine as 
far from his body as formerly, and more time is requiied 
to empty the bladder. In old and tight strictures 
the contraction may be so great that the urine passes 
in drops only. The stream may be so modified in 
shape that it is twisted, forked, peculiarly curved, or 
divided into several small streams ; but as its form de- 
pends chiefly on the shape of the meatus, and as it varies 
greatly in health and as a result of conditions other than 
stricture, these modifications are of little importance. 

The sexual fimctious of the urethra may be impaired 
early in stricture, but usually they are not disturbed 
until the obstruction is sufficient to prevent the forcible 
ejaculation through the urethra of the semen, which then 
dribbles from the meatus after subsidence of the erection, 
or, in case of very tight stricture, is forced back into the 



ORGANIC STRICTVRE OF THE URETHRA. S49 

bladder, to be discharged with the next flow of urine. 
The patient consequently is sterile. Ejaculation may 
be followed by pain in the urethra just back of the stric- 
ture, or in the bulb or the perineum, and the semen may 
be mixed with blood. If some of the meshes of the cor- 
pus spongiosum, and possibly of the corpora cavernosa, 
are occluded by the stricture-growth, the free flow of 
blood through these bodies is prevented, and erections 
are painful or are so imperfect as to render the patient 
impotent. In old cases sexual desire is diminished or 
entirely absent, but in recent cases the slight inflamma- 
tion back of the stricture may serve to stimulate and 
irritate the sexual organs. 

Local pains varying greatly in character occur at the 
site of the stricture, in the glans penis, testicles, cord, 
perineum, rectum, bladder, and even in more remote 
parts of the body. In stricture of small calibre there 
is usually some vesical tenesmus during the entire act 
of urination. While many of the pains are undoubtedly 
reflex in character, many of them are due to the presence 
of posterior urethritis, cystitis, or to other complications 
of stricture. 

TJie urine usually contains some pus, and shreds com- 
posed of epithelium and pus-cells, but it is otherwise 
normal unless cystitis be present, when it has the cha- 
racteristics of urine in cystitis from other causes. Keyes 
reports several cases of stricture in which haematuria was 
the only symptom. 

Constitutional symptoms are not directly produced by 
stricture until late in the disease, when the almost con- 
stant, painful attempts to force urine through the narrow 
opening may allow the individual no rest, and may re- 
sult in complete exhaustion, and, if unrelieved, in death. 



550 SYPHILIS AND THE VENEREAL DISEASES. 

Stricture rarely reaches this stage, however, without pro- 
ducing cystitis and other results and complications of 
stricture ; these secondary disorders present their own 
characteristic symptoms and may result fatally. Among 
the chief complications and results of stricture are inflam- 
matory and other disorders of the bladder, ureters, and 
kidneys ; urinary calculus ; epididymitis ; prostatitis ; 
perineal abscess ; urinary extravasation and fistula ; 
hemorrhoids (from pressure on the veins during strain- 
ing efforts to empty the bladder) ; and disturbance or 
obliteration of the sexual functions. 

Mental disturbance, as in other diseases of the genito- 
urinary organs, is often extreme and difficult to over- 
come. Sexual hypochondriacs who are suffering from 
ill-defined pains and sensations or from other functional 
disturbances due to faulty sexual hygiene not infre- 
quently imagine themselves the subjects of stricture, 
and are often reluctant to accept any other explanation 
of their sensations or fancied disorder. 

Fistula and extravasation are immediate results of 
severe forms of stricture. When ulceration occurs in 
some portion of the urethra — usually one of the sacculi 
or distended follicles — back of a stricture, and a few drops 
of urine escape into the surrounding tissues, abscess fol- 
lows. Such an abscess may open again into the urethra 
and produce an internal blind fistula; but it usually 
opens externally, and, retaining its connection with the 
urethra, produces urinary fistula. A blind internal fis- 
tula may persist as such for some time, and may be felt 
as a hard lump in the periurethral tissue, but it usually 
inflames and fills with pus, which eventually finds an ex- 
ternal outlet. Instead of forming a single fistula, pus in 
the periurethral tissues may burrow slowly in several 



ORGANIC STRICTURE OF THE URETHRA. 55 1 

directions and discharge through a number of external 
openings in the perineum, scrotum, body of the penis, 
thighs, groins, or nates. Civiale reported such a case in 
which the urine afterward escaped through fifty-two ex- 
ternal openings. Usually, however, one fistula forms at 
a time and serves as an outlet for the urine. The walls 
of such a fistula are soft at first, but, influenced by 
contact with urine, they gradually undergo changes 
similar to those in stricture-formation, become hard and 
callous, and contract until the channel becomes too 
small to allow the escape of urine. A new abscess 
forms, and terminates in a new fistula which pursues a 
career similar to the one preceding, and the process may 
thus be continued indefinitely. Instead of opening on 
the surface, a fistula may find an exit in the rectum. 

If a sufficient portion of the urethral mucous mem- 
brane back of a stricture is destroyed or gives way at 
one time to allow a large quantity of urine to escape 
into the surrounding tissues, extravasation of urine fol- 
lows. This unusual and serious complication of stric- 
ture is described by Keyes as follows : 

"In infiltration the urine may take any one of five 
directions : 

" I. It may, when small in quantity, get out of the 
urethra, but not penetrate Buck's fascia, in which case it 
may long remain confined to one spot in the perineum 
as a hard rounded swelling, like the blind internal fistula 
already described. 

" 2. It may find its way rapidly through the meshes 
of the corpus spongiosum, and cause gangrene of that 
body, with sloughing of the glans penis, preceded by 
coldness and the appearance of a black spot upon the 
glans. 



552 SYPHILIS AND THE VENEREAL DISEASES, 

'' 3. It may burrow inside of Buck's fascia, but out- 
side of the corpus spongiosum, forming a fistula opening 
behind the glans penis near its root, a hard ridge mark- 
ing the course of the fistula within Buck's fascia. 

" 4. It may escape behind the triangular ligament into 
the cavity of the pelvis. 

"5. It may escape outside of the common fascia of 
the penis, in front of the triangular ligament, in which 
case it rapidly distends the perineum, the scrotum, and 
the connective subcutaneous tissue of the penis, and 
mounts up over the abdomen, and may also, more rarely, 
perforate the deeper layer of the superficial perineal 
fascia, and descend upon the thighs. 

" When extensive infiltration of this sort occurs, all 
the parts affected becomes cedematous ; gases form in 
the connective tissue, causing emphysema and making 
the tissues crackle when pressed by the finger. Dark 
spots soon appear, indicating gangrene, and extensive 
portions of tissue may slough unless relief be promptly 
afforded. 

" The constitutional symptoms are those of shock. A 
chill usually occurs, followed by great depression, a cold 
clammy skin, feeble, quick, irregular pulse, hurried res- 
piration, furred tongue, complete anorexia, symptoms of 
septicaemia, and death. 

" When urine escapes behind the triangular ligament 
— which it does more rarely — it infiltrates deeply around 
the prostate and rectum well back in the perineum, 
around the bladder and up behind the pubes, forming 
abscesses in the cellular tissue of the hypogastrium, or 
perhaps deep pelvic abscesses." 

Keyes reports his own experiments and quotes those 
of Mengel to show that normal urine injected in small 



ORGANIC STRICTURE OF THE URETHRA. 553 

quantities into healthy tissues is absorbed without injur- 
ing" them, and beheves that if urine is evacuated by 
operation as soon as it has extravasated, serious gan- 
grene may often be averted. If the urine be decom- 
posed before its escape, as is often the case, or if infec- 
tious matter from the urethra be carried into the tissues 
with the urine, gangrene is certain to follow. 

In very rare instances some portion of the bladder, 
instead of the urethra, may rupture. This accident 
is followed by an extravasation of urine that almost 
invariably terminates fatally. 

Fistula and extravasation occur only in old and 
neglected cases of stricture, and are almost never found 
outside of dispensary and hospital practice. 

Instrumentation of the Urethra. 

Before attempting the use of instruments in the ure- 
thra, the student should become thoroughly familiar 
with the anatomy of the urethra and the perineum and 
with the landmarks of these regions. The following 
characteristics of the urethra should also be borne in 
mind : 

The meatus, as a rule, is the narrowest point in a nor- 
mal urethra, while the membranous portion is nearly as 
narrow. In addition to these two points of decided nar- 
rowing in the urethra, the pendulous portion may con- 
tain one or more points of slight constriction, usually 
situated in the second or third inch from the meatus, 
which points are recognized only when the urethra is 
fully dilated. The urethra also contains three decided 
enlargements. The first is the fossa navicularis, in the 
roof of which, about half an inch from the meatus, is 
a mucous flap forming the lacuna magna, which often 



554 SYPHILIS AND THE VENEREAL DISEASES. 

catches the points of fine instruments that have been 
improperly directed, in this region, to the upper wall. 
The second enlargement is in the bulb, which, of all por- 
tions of the urethra, is the most distensible and elastic, 
and therefore most liable to damage from the unskilful 
use of steel instruments. The third enlargement is in the 
prostatic portion (Fig. 27). 

The pendulous urethra is freely movable, and its curv- 
ature depends on the position of the penis, but the 
portion of the urethra extending from a little in front 




Fig. 27. — The prostatic {a), membranous {b), and spongy portions {c) of the normal 
uretlira (Thompson). 



of the triangular ligament to the neck of the bladder 
has normally a fixed curve. This portion of the ure- 
thra, and especially its floor, is not wholly immovable, 
and usually the curve may be nearly obliterated by the 
forcible introduction of straight instruments. Such a 
procedure is always painful, and usually is attended by 
danger of rupturing the urethra. It is of great import- 
ance, therefore, that all inflexible instruments intended 
for use in the deep urethra should be made with a curve 
corresponding closely with the fixed (subpubic) curve of 
this portion of the urethra. In the large majority of 
cases this curve is an arc of a circle three and one- 
fourth inches in diameter, the cord of this arc being two 



ORGAAUC STRICTURE OF THE URETHRA. 



555 



and three-fourths inches long (Fig. 28). An instrument 
made with a curve of this shape and length (generally 
known as " the Thompson curve ") will pass readily 
through the normal deep urethra, while an instrument 
with any other curve will pass with difficulty and is 




Fig. 28. — A .g ^ shows ihe proper curve (reduced in size) for unyielding male ure- 
thral instruments. C B D shows an improper curve (Tiemann). 



liable to injure the urethra. In old men and in those 
in whom the prostate is enlarged or the bladder is dis- 
tended the curve may be a little longer than the one 
described above. 

Guyon called attention to the fact that the fixed curve 
is found in the roof only of the urethra, since the floor 
is elastic, extensible, and soft, yields readily, before in- 
struments, \vhich it therefore cannot support or guide, 
is lacerated or ruptured with comparative ease, and is 
less regular in formation than the upper wall. The 
latter is shorter, less movable, more regular and con- 
stant in its curve, smoother and firmer, less easily dam- 
aged, less vascular, and less intimately connected with 
important structures than the lower wall. The prac- 
tical deduction is obvious : in passing instruments 
through the urethra, after the fossa navicularis is 



556 SYPHILIS AND THE VENEREAL DISEASES. 

passed the point should be kept closely against the 
upper wall. 

Cathctei'ism or Sounding of the Urethra. — The steel 
sound plays a most important part in the treatment 
of urethral disease, and the ability to introduce it 
properly and skilfully is one of the first requirements. 
The requisite skill cannot be acquired without practice, 
and the student should avail himself of every oppor- 
tunity for passing the sound or the catheter, both in 
dead and in living subjects. No amount of experience 
and practice, however, will justify the rough or forcible 
passage of a sound or a catheter ; the operation should 
invariably be performed with the greatest gentleness and 
patience. The beginner should make it a rule never to 
use any force. It is always best to know how to pass 
the sound with either hand, but in the following de- 
scription, as a matter of convenience, the use of the right 
hand is implied : 

The patient, with his thighs separated, should lie on 
his back on a firm table or couch. He should be made 
as comfortable as possible, both physically and mentally, 
in order to secure complete relaxation of all the muscles. 
To this end his fears should be removed by assuring him 
that if the instrumentation proves painful it will be stopped 
at once. The surgeon, standing at the patient's left, gently 
holds the penis just back of the corona with the left hand, 
while in the right hand he holds the sound, which has 
been properly cleaned, warmed, and anointed. With the 
sound held lightly, the shaft parallel with the patient's 
groin and near the skin, and with the handle well de- 
pressed (Fig. 29), the tip of the instrument is inserted 
in the meatus, and the penis is gently slipped up over 
the sound, which may be allowed to drop into the ure- 



ORGANIC STRICTURE OF THE URETHRA. 



557 



thra by its own weight. The penis should gently be 
put on the stretch to efface the folds of the urethral 




Fig. 29. — Sounding of the urethra (Keyes). 



mucous membrane and to enable the point of the sound 
to gravitate as far as possible toward the bulb. With 




Fig. 30. — Sounding of the urethra (Keyes). 

the left hand still holding the penis, the handle of the 
instrument is steadily carried over the surface of the 



558 SYPHILIS AND THE VENEREAL DISEASES. 

abdomen to the exact median line of the body (Fig. 30). 
Without elevating the handle of the sound, the latter is 
then gently pushed toward the feet of the patient, while 
the left hand gathers up the scrotum, testicles, and penis 
and makes slight upward traction upon them. The point 
of the sound should be followed closely throughout by 
the little finger of the left hand, and when the point has 
passed to the perineum and the curve of the instrument 
can be felt back of the scrotum, the penis and the tes- 




Sounding of the urethra (Keyes). 



tides are dropped and the fingers of the left hand are 
placed on the perineum, where they give support to the 
lower wall of the urethra and keep the point of the in- 
strument well against the upper wall. Up to this time 
the handle of the sound has been held constantly close 
to the abdominal wall. The handle should now be 
lifted and gently carried toward the feet, thus describ- 
ing an arc of a circle exactly in the median line of the 
body. When the handle of the sound has reached and 



ORGANIC STRICTURE OF THE URETHRA. 



559 



passed the perpendicular (Fig. 31), the left hand leaves 
the perineum and supports the handle of the sound, 
while the right hand presses upon the pubes and re- 
laxes the triangular ligament, allowing the sound by 
its own weight to slip through the membranous and 
prostatic portions of the urethra into the bladder (Fig. 
32). That the sound has entered the bladder may be 
demonstrated by partially rotating the handle, showing 
that the tip of the instrument is free. 




Fig. 32. — Sounding of the urethra (Keyes). 

To remove the sound the handle is carried through 
motions exactly the reverse of those pursued during its 
introduction. Neither force nor traction is necessary. 

Force is required for the introduction of a sound in 
exceptional cases only, and should never be used by any 
but the expert. The sound should be held lightly be- 
tween the tips of the thumb and the fingers, as a firmer 
grasp would interfere with the sense of touch, which is 
of great importance, and would increase the danger of 
unconsciously using force. It should never be forgotten 
that the sound is a lever of the first class, the tip form- 
ing its short and the handle its long arm, and that the 



560 SYPHILIS AND THE VENEREAL DISEASES. 

pressure produced by the point upon the urethral wall 
is many times greater than that exerted by the hand of 
the operator upon the handle. Even in a normal urethra 
the progress of the sound may be arrested by urethral 
spasm, which occurs most frequently at the beginning 
of the membranous urethra. The gripping of the sound 
by the muscle-fibres produces a sensation readily recog- 
nized by the experienced hand holding the instrument. 
If the sound be held quietly against the contracted mus- 
cles, they soon relax and allow the instrument to pass. 
Coaxing rather than forcing is the rule at all times when 
using an instrument in the urethra. 

The tip of the sound should always be kept steadily 
in the median line, and all irregular, jerking, or wab- 
bling movements should be avoided, as these produce 
unnecessary motions of the tip in the urethra, and the 
resulting disturbance of the urethral walls is the most 
frequent cause of pain in this operation. A support for 
the surgeon's elbow is usually serviceable. 

Beginners experience the most difficulty when the tip 
of the sound is passing from the large, distensible, and 
movable bulbous urethra to the narrower membranous 
portion. If the handle be raised from the abdomen too 
soon, the tip catches above in the subpubic ligament ; 
while if the tip is not held well up against the upper wall 
by the fingers on the perineum, it may bury itself in the 
loose and movable floor below the orifice. Figure 33 
shows the bulbous urethra greatly distended by the tip 
of a sound that has been allowed to fall and turn over. 
When the tip of the sound is arrested at this point, the 
curve of the instrument bulges out in the perineum as the 
shaft is depressed between the thighs, and if the handle 
be released, it springs back toward the perpendicular. 



ORGANIC STRICTURE OF THE URETHRA. 



561 



In such a case the sound should be withdrawn an inch 
or two and reintroduced, care being taken not to raise the 
handle too soon and to keep the tip against the upper 




Fig. 33. — Relative positions of triangular ligament and bulb of urethra (diagram- 
matic, from Culver and Hayden). 



wall. A few gentle manoeuvres should succeed in pass- 
ing the instrument into the bladder, unless there be stric- 
ture or unless the sound is too large for the urethra. 

While decided pain should not be produced by the 
passage of a sound or a catheter as described above, 
even a normal urethra shows some resentment at the 
introduction of a foreign body. Slight pricking, sting- 
ing, or tickling sensations are usually felt by the patient 
as the tip of the sound comes in contact with the mucous 
membrane, and as the instrument dilates the membranous 
and prostatic portions the desire to urinate may become 

36 



562 SYPHILIS AND THE VENEREAL DISEASES. 

SO strong that the patient declares he cannot retain his 
urine another moment. In sensitive patients the opera- 
tion may produce nausea or even complete syncope. 
These disturbances are usually most marked in a young 
man having his urethra explored for the first time, since 
the sensitiveness of the urethral mucous membrane is 
rapidly lessened as a result of repeated instrumentation. 
The first micturition following the use of an instrument 
in the urethra is usually attended by some smarting or 
burning. Urethral (urinary) fever, prostatitis, or epididy- 
mitis occasionally results even when every precaution is 
supposed to have been taken ; but these results are fre- 
quently due to forcible or careless instrumentation of the 
urethra, or to the use of instruments that are not clean 
and aseptic. 

Instnnnents. — Of all the instruments used in the treat- 
ment of stricture, the steel sound is the most important. 
Steel sounds for use in the deep urethra measure about 
nine inches from the tip to the junction of the shaft and 
the handle, and are blunt or conical. Blunt sounds are 
of a uniform diameter throughout their entire length ; 
conical sounds are several sizes (from 3 to 7 sizes French) 
smaller at the tip than in the shaft, the conicity extend- 
ing from the tip to about the beginning of the curve. 
The blunt sound is chiefly valuable for exploration and 
for the treatment of urethral lesions other than stricture. 
The slightly conical sound is the most generally useful 
and the most economical, as fewer sizes are needed. 
All steel sounds for use in the deep urethra should pos- 
sess the curve already described, should be polished per- 
fectly smooth, should be nickle-plated, and should have 
the size of the shaft plainly stamped on the handle. 

Tlie scale used for determining the size of urethral in- 



ORGANIC STRICTURE OF THE URETHRA. 



563 



\ 



struments varies greatly in different countries and, unfor- 
tunately, with different instrument-makers. The French 
scale furnishes a definitely fixed standard, and is that to 
which all numbers in these pages refer. By this scale 
the number on a sound indicates its circumference in 
millimeters. No. i is one millimeter, No. 2 two milli- 
meters, and so on through the entire scale. The divisions 
on this scale are so small that it is 
rarely necessary to have sounds repre- 
senting all the numbers, especially in 
conical and in flexible instruments. 
In making a set every other number 
may be omitted, so that ten conical 
steel sounds ranging from 15 to 33 in 
sizes (the tip of each being three or four 
sizes smaller than the shaft) will meet 
the requirements of all but exceptional 
cases. As manufacturers of instru- 
ments do not yet use a uniform scale, 
and as most flexible instruments are 
neither accurately nor plainly marked, 
the surgeon should own an accurate 
scale-plate (Fig. 34), on the two faces 
of which are marked French, English, 
and American scales, as well as inches 
and millimeters. 

Sliort steel sounds, made straight or 
with a very short curve at the tip, are 
convenient for use in the anterior ure- 
thra; they are, however, not necessary, since the long 
sound need be passed into the urethra no further than 
is desired. 

The bulbous bougie (bougie a botile) is the instrument 




Fig. 34. — Handerson' 
gauge (Tiemann). 



564 SYPHILIS AND THE VENEREAL DISEASES. 

most used for determining definitely the location and 
calibre of strictures (Fig. 35). The head should be short, 



Fig. 35. — Bulbous bougie (Tiemann). 

and the shoulder should join the much smaller shaft at 
almost a right angle. These instruments made of metal 
are to be preferred when large sizes are to be used in 
the anterior urethra only, but for general use the flexible 
gum bougies a boiile are better. Otis's urethrometer 




Open. 
Fig. 36. — Otis's urethrometer (Tiemann). 

(Fig. 36) is intended to serve the purpose of bulbous 
bougies of different sizes. After introduction into the 
urethra the bulb may be made larger or smaller as de- 
sired, and the size is indicated on the scale at the handle. 
A soft-rubber cap covers the bulb, to keep the wires from 
tearing the mucous membrane. This instrument is con- 
venient when it works well and is carefully manipulated, 
but it usually causes more pain than do the bulbous 
bougies, and even in careful hands the rubber cap is 
liable to be torn or to be left in the urethra. 

Silver catheters should correspond in shape and size 
with the blunt steel sounds. They are of occasional 
service in the large sizes, and should be introduced in 
the same manner as the steel sound. 

Flexible bougies (Fig. 37) are necessary in the treat- 
ment of stricture of small calibre ; in the larger sizes. 



ORGANIC STRICTURE OF THE URETHRA. 



565 



they are often valuable, especially for beginners. As a 
rule, even the expert should use flexible bougies for all 
sizes below 15 or 18, in order to avoid the danger of 



Fig. 37. — Olivary gum bougie (Tiemann). 

making a false passage. Of these bougies, the conical 
are the best and most serviceable, though for the 
larger sizes the olive-tip bougie, if connected with the 
shaft by a slender, perfectly flexible neck, is preferable. 
They are made in all sizes from the filiform up. 

Flexible catheters are made of the same size and shape 
as bougies. Some of these catheters are furnished with 
a metal stylet which stiffens them during introduction. 
This stylet is of only occasional value. The Mercier 
catheter (Fig. 38) is an excellent instrument in difficult 



Fig. 




Mercier elbowed catheter (Tiemann). 



cases, and especially if the prostate be enlarged. The 
tip should not be too stiff, as it often is in those of Eng- 
lish manufacture. 



X. 



Fig. 39.— Gouley's whalebone bougies (Tiemann). 

Filiform bougies (Fig. 39) are necessary in the treat- 
ment of all strictures of very small calibre — tight strictures. 
The best filiforms are made of whalebone with fine bulbous 



I 



566 SYPHILIS AND THE VENEREAL DISEASES. 

tips. By placing them in hot water for a few minutes 
the ends may be so bent or twisted that the point will 
enter an eccentric opening in a stricture which a straight 
instrument would be unable to penetrate. If the two 
ends of a filiform bougie are thus bent in the same direc- 
tion, when the tip engages in the stricture the outer end 
will serve as an index to the exact location of the open- 
ing, which can thus be found with much less difficulty at 
the next sitting. A filiform bougie, when it has been 
passed through a small and difficult opening in a stric- 
ture, may be used as a guide for a larger instrument. 
For this purpose the bougie should be at least eighteen 
inches long. Dr. E. A. Banks has devised a whalebone 
bougie which is filiform at its tip and throughout its first 
two or three inches, and then increases in size to form a 
larger shaft which can be pushed on into the stricture to 
dilate it. Filiforms are also made with caps on the outer 
end that can be screwed on to larger instruments which 
may thus be conducted through the stricture. These 
bougies are dangerous, as the caps may become loose 
and the filiform bougie may be left in the stricture or in 
the bladder; besides, they offer no advantage over either 
of the two preceding methods. Whalebone bougies fre- 
quently become cracked, rough, or frayed as a result of 
keeping and handling; consequently it is necessary to 
inspect each bougie (as should be done with all soft in- 
struments) just before using, to make sure that it is sound 
and smooth. 

Tunnelled sounds and catheters (Fig. 40) are so made 
that they can be threaded over a filiform bougie and 
thus be guided safely into the bladder. They should 
have a short curve, and the short tunnel should be large 
enough to allow the guide to slip through it easily, with 



ORGANIC STRICTURE OF THE URETHRA. 567 

edges smooth and rounded to prevent cutting the guide. 
To use the tunnelled sound safely and to advantage, at 
least five or six inches of a long filiform bougie should 
be passed into the bladder. The tunnelled sound is 




Fig. 40. — Gouley's catheter-staff (Tiemann). 

then threaded over the guide and slipped down to the 
point of the stricture. Here it is gently pressed forward 
through the stricture as the guide is slowly and gently 
drawn out. If the guide becomes fast in the larger in- 
strument, both guide and sound should be withdrawn 
until the former is again freely movable. Failure to 
observe these precautions may result in a false passage 
or in cutting the guide in two and leaving one end of it 
in the stricture. 

Introduction of Flexible Instruments. — In the use of 
soft and flexible instruments slight pressure or force is 
allowable, though some of the rubber bougies are stiff 
enough to do damage if carelessly used. The position 
of the penis during the introduction of flexible instru- 
ments is not a matter of great importance except for the 
small-sized instruments, for which the penis should be 
held parallel with the thighs and should be put lightly on 
the stretch, to make the canal as straight as possible and 
to efface the folds of mucous membrane in which the fine 
points of small instruments are frequently caught. 



568 SYPHILIS AND THE VENEREAL DISEASES. 

For the introduction of filiform bougies the urethra 
should first be filled with warm, slightly benzoinated or 
carbolated olive oil. The points of these fine instru- 
ments are often caught, even in the healthy portion of 
the urethra, by folds of mucous membrane or in the 
sinuses of Morgagni. When this accident occurs the 
bougie is withdrawn an inch or more ; the tip, bent to 
form an angle with the shaft, is then rotated in another 
direction and again advanced. These manoeuvres are 
repeated gently, and, if necessary, many times, until 
the tip engages in the orifice of the stricture. To 
determine whether a bougie has entered the opening 
of a stricture or a blind pocket, it should be slightly 
withdrawn and advanced : if it be engaged in a stricture, 
the grip of the latter upon the instrument can be felt 
plainly by the hand of the operator. 

In old and tortuous strictures, with many pockets, 
lacunae, and partial false passages (Fig. 26) ready to 
entangle the point of a filiform bougie, it may be 
impossible to find the opening with a single instru- 
ment. In such a case a filiform bougie is passed 
until it is caught, when it is held in place and 
another bougie is passed by its side. In this way the 
urethra may be filled with a number of these fine 
instruments, each of which should repeatedly be with- 
drawn slightly, partially rotated, and again advanced, 
until one of them engages in the orifice of the stricture 
and passes into the bladder. The successful perform- 
ance of the above-described procedure calls for a steady 
hand, a sensitive and delicate touch, a large amount of 
patience, and the greatest gentleness in every movement, 
lest the mucous membrane be damaged by much manip- 
ulation. The search ma\' sometimes be continued for 



ORGANIC STRICTURE OF THE URETHRA. 569 

an hour or more, but the production of hemorrhage or 
of marked irritation at once renders further attempts 
useless until the urethra has had a rest of at least 
twenty-four hours. 

Relative Value of Steel and of Flexible Instritments. — 
The polished steel sound, of proper curve, in the hands 
of an expert, can be introduced into the urethra with 
less discomfort than can any other instrument, but it 
should not be used for sizes below 15 or 18, for fear of 
making a false passage. For the smaller sizes the flexi- 
ble instruments are safer and better. They may often 
be used in the larger sizes to advantage. The chief 
objections to them are that they produce more irritation 
in the urethra, and therefore more frequently provoke 
urethral spasm, and that they are less rapidly effective 
in dilating stricture than the steel sound when the latter 
is used with sufficient skill and care. They are, more- 
over, more difficult to clean and less durable. On the 
other hand, they are not capable of doing so much 
damage when used by one not specially trained in the 
proper introduction of the steel sound. The best 
flexible instruments have a foundation of woven linen 
covered with a smooth elastic composition. When new 
and in cool weather, the black French instruments are 
softer and better than the English, but they do not last 
so long; in hot weather they often become too limp to 
be of any use and are easily spoiled, as softening of their 
outer coating allows them to stick together and be- 
come rough. The English (yellow) bougies are firmer 
and more durable, and, if the softer ones be selected, are 
the best. If too stiff, they can be made more flexible by 
placing them in hot water for a few minutes just before 
usincf. 



570 SYPHILIS AND THE VENEREAL DISEASES. 

All flexible instruments sooner or later wear out or 
become hard and brittle ; consequently they should 
always be examined just before using, to make sure that 
they are sound and smooth. This remark is especially 
true of the soft catheters, made without the woven 
foundation, which every general practitioner is supposed 
to carry in his case. It happens occasionally that the 
tip of one of these old instruments breaks off and is 
left in the urethra. Fortunately, in the majority of 
cases, if left alone, the constriction about the piece 
relaxes after a few hours, and the fragment is washed 
out during the next urination. 

Care of Instrtnnenis. — The principles of antiseptic 
surgery should be followed strictly in the care and use 
of all urethral instruments. Failure to observe these 
principles too often results in urethral fever, urethritis, 
cystitis, epididymitis, prostatitis, abscess, and other dis- 
agreeable and dangerous complications. All instruments, 
immediately after use, should be washed thoroughly 
with soap and warm water. Antiseptic solutions have 
little effect upon an instrument covered with oil or vase- 
line and smeared with pus, blood, or other matter. 
Moreover, if rubber instruments are allowed to remain 
covered with oil, vaseline, or fat, they soon become 
rough and useless. Steel instruments are best sterilized 
by boiling or by placing them for twenty minutes or 
half an hour in a steam-sterilizer. Before use they may 
be placed for a few minutes in a 5 per cent, carbolic-acid 
solution. Rubber and whalebone instruments should be 
placed, before use, in a solution of bichloride of mercury, 
I : 1000. Refined vaseline, cosmoline, and albolene are 
the best lubricants for general use, since they do not be- 
come rancid. When desired, carbolic acid (2 per cent.) or 



ORGANIC STRICTURE OF THE URETHRA. 57 1 

boric acid (sj to .Ij) may be added. As a rule, instru- 
ments should be warmed before use in the urethra. 
This precaution renders their introduction less irritating 
to the mucous membrane, and the production of spasm 
less frequent. In the absence of warm water, steel in- 
struments may quickly be warmed by rubbing them 
rapidly through a towel held in the hand. 

Steel instruments should be kept in cases made to fit 
them, as they are otherwise easily nicked or scratched. 
The slightest defect, such as a scratch or a rust-spot, in 
the surface of an instrument may cause urethral irrita- 
tion, and may, moreover, serve as the lodging-point of 
infectious matter. Such an instrument should always 
be laid aside until properly repaired. Rubber instru- 
ments should be kept between layers of cotton or in 
narrow pasteboard trays lined with paper that is thrown 
away when soiled. In hot weather they should be 
dusted with finely powdered talc or otherwise separated, 
to keep them from adhering — an accident that almost 
invariably roughens and ruins the instrument. 

Cutting instruments and the methods of their use are 
described in connection with the operations for which 
they are intended. For the benefit of the beginner, 
a summary of all other instruments necessary in the 
diagnosis and treatment of stricture is here given. 
The French scale is used, and in forming sets of in- 
struments every other (odd or even) number may be 
omitted. 

Ten conical steel sounds, Nos. 15 to 33; a corre- 
sponding set of short steel sounds, for use in the anterior 
urethra (convenient, but not necessary) ; two or three 
silver catheters, Nos 18 to 24; a set of bulbous bougies, 
Nos. 7 to 33 (the larger sizes may be metallic if pre- 



572 SYPHILIS AND THE VENEREAL DISEASES. 

ferred); a set of French or English conical, flexible 
bougies, Nos. 5 to 20, or to 33 if desired; half a dozen 
soft catheters, Nos. 6 to 20 ; as many Mercier catheters, 
and one or two of larger size ; half a dozen short and 
three or four long whalebone filiform bougies ; a set of 
tunnelled conical steel sounds with short curve, Nos. 
6 to 18; two or three tunnelled (not conical) catheters, 
Nos. 6 to 10; a Banks whalebone bougie; and an accu- 
rate gauge. If the surgeon is within easy reach of sur- 
gical supplies the number of soft catheters should be 
reduced, as these instruments often deteriorate and 
become useless after a few months. 

Diagnosis. — The instruments of precision furnished 
the surgeon render the diagnosis of stricture compara- 
tively easy. The chief difficulty at present lies in distin- 
guishing between beginning strictures of large calibre 
and normal points of narrowing in the urethral wall. 

The indications for exploring the urethra are found in 
the presence of one or more of the symptoms of stricture, 
already described, appearing a number of months or 
years after urethritis (usually prolonged gonorrhoea) or 
urethral injury. Needless instrumentation of the urethra 
should always be avoided. Though the proper explora- 
tion of the urethra is usually attended by no worse re- 
sults than some discomfort or pain to the patient and 
some smarting or burning in the urethra at the next 
micturition, it happens occasionally that the apparently 
careful and skilful passage of a steel sound through a 
normal urethra is followed by syncope, shock, urethral 
fever, epididymitis, prostatitis, etc. If the urethra be 
diseased, if force be used, if the operator be careless or 
unskilled, or if his instruments be rough or soiled, these 
and other yet more unfortunate results of urethral instru- 



ORGANIC STRICTURE OF THE URETHRA. 573 

mentation occur not infrequently. Instruments should 
not be used in the urethra if there be a decided discharge 
from the meatus, or other evidences of urethral inflam- 
mation or irritation. 

Exploration of the urethra for the first time should be 
begun by the introduction of a blunt steel sound of the 
largest size that will pass the meatus without stretching 
the latter sufficiently to cause pain or to produce the 
characteristic evidence of an over-stretched meatus — 
namely, a narrow white (anaemic) line at the edge of the 
orifice and in contact with the instrument. As a rule, 
if such an instrument pass easily into the bladder, stric- 
ture is absent. The exceptions to this rule are consid- 
ered later. If the instrument meets with obstruction in 
the urethra and fails to pass, a series of blunt sounds 
gradually decreasing in size should be used until one 
is passed. Below size 15, soft instruments should be 
used. When an instrument has been passed, it should 
be left in position (unless it is producing pain or irrita- 
tion) long enough for the fingers to explore the pendu- 
lous urethra for external evidences of stricture, which 
may be found in the form of circular or irregular bands 
of thickening and induration. In this way valuable in- 
formation may be gained, and further instrumentation 
for purposes of diagnosis is often rendered unnecessary. 

In many cases, however, accurate location and meas- 
urement of stricture is best accomplished by the use of 
bulbous bougies. An instrument with a bulb corre- 
sponding in size to the sound that has passed the stric- 
ture is properly prepared and gently inserted down to 
the anterior face of the stricture, where it is arrested. 
If the bulb does not pass the stricture, a smaller instru- 
ment is selected and passed into the bladder. As it is 



574 SYPHILIS AND THE VENEREAL DISEASES. 

withdrawn it is again arrested as its shoulder reaches 
the posterior surface of the stricture. If the distance of 
the meatus from the end of the handle be measured and 
noted when the bulb is arrested, both in entering and in 
withdrawing, not only the location and calibre but also 
the approximate thickness of the stricture may be de- 
termined. In those unusual cases in which stricture is 
multiple there is no difficulty in locating and measuring 
each, if the anterior stricture is of larger calibre than the 
deeper one. If the reverse is true the Otis urethrometer 
may be used, though the diagnosis of the deeper stricture 
is of less practical value, since it does not call for treat- 
ment until the stricture in front of it has been dilated. 

Several sources of error should always be considered 
in the use of bulbous instruments. They produce more 
irritation, and therefore more frequently provoke urethral 
spasm, than do blunt or conical sounds, and, moreover, 
they are less effective than the latter in overcoming 
spasm or in detecting the characteristics which distin- 
guish it from organic stricture. In withdrawing the 
instrument the shoulder of the bulb, in passing from the 
prostatic to the membranous urethra, frequently catches 
on the posterior layer of the triangular ligament and 
produces a sensation closely resembling that produced 
by stricture. In the pendulous urethra the shoulder of 
the bulb may be arrested at one or more points of nor- 
mal narrowing frequently found in the first three inches 
from the meatus. The danger of error in diagnosis is 
lessened if the bulbs be used in connection with the steel 
sound as above described. 

The reasons for beginning with a full-sized steel sound 
are several : it produces less irritation than any other 
instrument ; often it will easily enter the bladder when 



ORGANIC STRICTURE OF THE URETHRA. 575 

bulbous sounds or smaller instruments fail to pass be- 
cause of the spasm excited or because of the finer points 
being caught in some of the folds or sinuses of the 
urethra; its ready passage may save much unnecessary 
instrumentation and irritation of the urethra ; the intro- 
duction of one or more steel sounds in a urethra lessens 
for a time the sensitiveness of the mucous membrane, so 
that other instruments which follow produce less irrita- 
tion and spasm than if used first. 

As a rule, the first sitting should be made as short as 
possible, since strictures — and individuals also — vary 
greatly in the amount of instrumentation they will 
endure without unfavorable results. If the introduction 
of the first sound proves very irritating, as may happen 
in nervous men, it is often wise to postpone further at- 
tempts for a day or two, even though the bladder has 
not been entered. After locating and measuring the 
stricture, unless there be urgent symptoms demanding 
immediate attention, no attempt at dilatation should be 
made for two or three days, until the irritation which 
will probably result from the examination has subsided, 
and the surgeon is given a chance to gain some idea of 
how sensitive the patient and his stricture are to instru- 
mentation. The patient should be warned that the next 
urination will probably be attended by some discomfort, 
and that he may notice a slight discharge from the 
meatus, or an aggravation of an existing one, for a few 
days. If indicated, an alkali or one of the balsams may 
be ordered, while small doses of quinine may be given 
to lessen the danger of urethral fever. 

The general health and habits of the patient should 
be investigated fully, and necessary corrections should 
be made. Of particular importance is a careful exami- 



576 SYPHILIS AND THE VENEREAL DISEASES. 

nation of the urine. If the latter contains pus, and espe- 
cially if it is decomposed and indicates the presence of 
cystitis, the patient should at once be put upon boric 
acid or salol in lO-grain doses four times a day, to 
lessen the danger of urethral fever and other complica- 
tions. The amount of residual urine in the bladder 
should be ascertained by passing a catheter immediately 
after the patient has urinated. 

The accurate diagnosis of strictures of large calibre 
may require cutting of the meatus before instruments 
of sufficient size can be introduced into the urethra. 
Until recently many surgeons, acting under the impres- 
sion that the operation was simple and harmless, have 
cut the meatus frequently and freely, simply as a matter 
of convenience in searching for possible stricture of 
large calibre. There is no doubt that the operation is 
often followed by harmful results. The gaping lips of 
a freely cut meatus are frequently the seat of a persistent 
gleety discharge, while the operation may greatly lessen 
the power of the individual to eject urine and semen 
from his urethra, so that dribbling of urine after mic- 
turition is not uncommon in these cases. If the meatus 
is abnormally small, and especially if it is rendered so 
by a thin band of tissue at the lower commissure, 
meatotomy should be performed to allow the entrance 
of a full-sized sound. The free division of the meatus, 
however, to allow the introduction of very large instru- 
ments is not warranted unless there be other and 
more urgent symptoms of stricture than a gleety dis- 
charge, or unless the latter has persisted for a year or 
more notwithstanding skilful and faithful treatment, in- 
cluding the best general and hygienic management. In 
such a case it is possible that a forming stricture, of a 



ORGANIC STRICTURE OF THE URETHRA. 577 

calibre as yet too large to interfere with the passage of 
an instrument of ordinary size, is responsible for the 
discharge, and, after other means of treatment have been 
tried, exploration of the urethra with instruments larger 
than will pass the normal meatus is proper. 

In such an examination the question at once arises, 
What constitutes the normal calibre of the urethra, and 
what size of instrument should pass unobstructed into 
the bladder ? On this point authorities differ, and it is 
evident that an exact answer to this question cannot be 
given, since the urethra is not a tube of uniform diame- 
ter, but is a closed canal or valve having normal points 
of narrowing. Dr. Otis maintains that the calibre of 
the urethra bears a constant relation to the circumfer- 
ence of the flaccid penis. But that such a relation is 
only approximate is evident when one considers the 
great variations in the size of the organ under the in- 
fluence of heat, cold, mental state, etc. Dr. Otis's scale, 
which is much too large, is as follows : When the cir- 
cumference of the flaccid penis is 3 inches, the urethra 
should receive an instrument of the size 30; 3 J inches, 
size 32 ; 3 J inches, size 34; 3I inches, size 36; 4 inches, 
size 38 ; 4J to 4J inches, size 40. These sizes do not 
indicate the normal calibre of the urethra, but the limit 
to which, according to Dr. Otis, the urethra can safely be 
distended. For purposes of diagnosis and treatment 
the majority of modern surgeons adopt a scale from four 
to eight sizes smaller than those named above ; they also 
recognize normal variations in the pendulous urethra. 

Many surgeons who adopt the larger scale find and 
treat a great many so-called " strictures of large calibre " 
that are really nothing more than simple, normal con- 
tractions of the urethra. This unnecessary stretching 
37 



5/8 SYPHILIS AND THE VENEREAL DISEASES. 

and cutting of the urethra not infrequently results in 
permanent and even distressing deformity. 

The diagnosis of stricture should, then, be reserved 
for a distinct contraction of the urethra, accompanied by 
a gleety discharge, frequent micturition, dribbling of urine 
after urination, or other symptoms of stricture. 

Prostatic hypertrophy may lead to a careless diagnosis 
of stricture of the deep urethra, but in the former dis- 
order the obstruction to the sound is situated more than 
six and a half inches from the meatus ; the handle of 
the sound must be depressed considerably more than 
usual before the tip enters the bladder ; a rectal exam- 
ination reveals the enlarged prostate ; the patient usually 
is over fifty years of age ; and there is a history of grad- 
ually increasing frequency of micturition, most marked 
at night. 

Treatment. — The directions already given for instru- 
mentation of the urethra are not repeated here, although 
their observance forms a necessary and most important 
part of the treatment of stricture. It should never be 
forgotten by the operator that the exercise of gentleness, 
caution, and patience is not only less dangerous but far 
more effective in the treatment of stricture (with the ex- 
ception of those cases in which a cutting operation is 
required) than is the employment of force. 

Dilatation. — In the large majority of strictures, either 
of the deep or of the pendulous urethra, that are not 
complicated by retention or by other urgent symptoms, 
gradual dilatation is the most efficient and safest method 
of treatment. By this method the stricture is dilated 
during successive sittings by a series of sounds gradually 
increasing in size. The principles given for the intro- 
duction of the steel sound should be carefully studied 



ORGANIC STRICTURE OF THE URETHRA. 579 

and applied. Each sound or bougie should be cleaned, 
sterilized, warmed, and lubricated before it is used in the 
urethra. To further lessen the danger of urethral fever 
during treatment, the patient should take 10 or 15 grains 
of boric acid or of salol four times a day for thirty-six 
or forty-eight hours before and for an equal time after 
each sitting. The general health of the patient should 
be maintained, and he should fully understand that the 
success of the treatment, as well as freedom from dis- 
tressing complications which delay progress, will depend 
largely upon his living simply and hygienically. To- 
bacco, alcohol, and other stimulants, sexual indulgence, 
and severe exercise are especially harmful. Frequent 
examinations of the urine, and especially of the residual 
urine, are necessary to keep the surgeon informed regard- 
ing the condition of the bladder and of the kidneys. 

In strictures of large calibre the dilatation is best ac- 
complished by means of conical steel sounds. There is 
selected a sound of the same size as the exploring instru- 
ment that entered the stricture during the examination 
of two or three days previous; this sound is gently 
passed through the stricture. If it occasions no dis- 
tress, it should be allowed to remain in situ for five or 
ten minutes ; it is then withdrawn gently and the next 
larger size is used in the same manner. If the stricture 
is in the pendulous urethra, a short sound should be 
used, or the long sound should be arrested before enter- 
ing the bladder, to avoid unnecessary irritation. Usually 
the stricture may thus be dilated two or three numbers 
(French scale) at each sitting; but occasionally the 
same sound must be passed at several successive sit- 
tings before a larger one can be employed. This is a 
matter that must be decided in each case by the surgeon 



580 SYPHILIS AXD THE VEXEREAL DISEASES. 

in attendance, after watching the effect of instrumenta- 
tion upon the stricture and upon the individual. Dila- 
tation should be stopped for that day whenever it has 
been carried far enough to produce a drop or two of 
blood or to cause decided pain or irritation. When 
attempts at dilatation are followed by marked urethral 
irritation, with possibly slight pain in the testicles, and 
especially if a suggestion of chill or fever has resulted, 
the surgeon will content himself with slower progress. 
There is nearly always a temptation to use a little force 
and haste, but such attempts are usually followed by 
urethritis, epididymitis, or urethral fever, necessitating 
the suspension of further dilatation until the new com- 
plication is removed. The conical steel sound is not 
only a powerful lever of the 'first class, but it is also a 
wedge, and few surgeons realize, until they have pro- 
duced a false passage or met with other misfortune, how 
much force very slight pressure upon the handle may 
cause the point of such a sound to exert in the (usually 
damaged) urethra. Slight force may occasionally be 
necessary in the use of blunt instruments, but if a con- 
ical steel sound, properly held against a stricture for a 
few seconds, refuses to pass by its own weight, it should 
be withdrawn and a smaller size be substituted. 

At each sitting the dilatation should be begun by the 
introduction of a sound one or two sizes smaller than 
the largest sound used at the previous visit. It is 
always best to have the patient urinate in the surgeon's 
presence before passing the sounds, that the size of the 
.stream and the condition of the urine may be tested, 
and that the first urination after the operation may be 
postponed for a few hours. 

Valuable information bearing on the treatment of 



ORGANIC STRICTURE OF THE URETHRA. 58 1 

stricture may be obtained by watching the phenomena 
following the introduction of a sound into a stricture 
which is thus stretched slightly. When the instrument 
first enters, it is more or less tightly grasped, so that 
some force may be necessary to remove it, but if allowed 
to remain in situ a few seconds or minutes, the stricture 
relaxes and the sound moves through it easily ; the 
spasmodic element has been overcome and the stricture 
has been stretched mechanically. As a rule, the stream 
of urine is increased in size for a short time — possibly 
twenty-four hours — before congestion, or even inflamma- 
tion, in and about the stricture-growth follows ; the 
resulting swelling narrows the calibre of the urethra 
and therefore the size of the stream. At this time there 
is usually an increase in the discharge from the meatus, 
with other symptoms indicating irritation or inflamma- 
tion of the urethra. At the end of three or four days 
absorption begins ; the calibre of the stricture, and hence 
the size of the stream, enlarges ; the urethral discharg-e 
and other symptoms improve. This improvement con- 
tinues from a da}' or two to a week before contraction 
again begins. 

It is evident to one who stops to consider the signif- 
icance of the above-described phenomena that after 
stretching a stricture the next attempt at dilatation 
should be postponed at least beyond the stage of contrac- 
tion and irritation ; indeed, the best results are obtained 
when such instrumentation is delayed until just before 
the stricture again begins to contract. When the same 
instrument that was used a day or two before to dilate a 
stricture is reintroduced during the resulting stage of 
congestion, it passes with more difficulty and produces 
much more pain and irritation than when passed the first 



582 SYPHILIS AND THE VENEREAL DISEASES. 

time. Unless the operator appreciates the situation, he 
will probably conclude that he has an irritable stricture 
to deal with. A great many irritable strictures are un- 
doubtedly produced in just this way, as the result of too 
frequent and injudicious instrumentation. The com- 
monest mistakes in the treatment of stricture are of this 
charater, and beginners especially are inclined to make 
the intervals between visits for dilatation altogether too 
short. The results of such over-treatment are slow 
progress if any, an irritable stricture, a constantly con- 
gested and inflamed urethra, and not infrequently more 
serious complications. In different cases the proper in- 
terval may vary from three to ten days, depending upon 
the character of the stricture, the amount of dilatation 
accomplished each time, the amount and nature of the 
reaction, and the general health and habits of the indi- 
vidual. The decision must be based on a careful study 
of each case, and especially of the phenomena described 
above. As a rule, the most rapid progress and the best 
results in dilatation of stricture, when steel instruments 
are used, are obtained by sittings with intervals aver- 
aging from five to seven days. 

The treatment should be continued steadily through 
several weeks until the stricture has been dilated to the 
normal calibre of the urethra.^ By this time the symp- 
toms will usually have disappeared, with the exception 
of traces of the gleety discharge, which will probably 
disappear as instrumentation is suspended. 

The treatment must not end here, however, if it is to 
result in any permanent benefit, for if left alone the great 
majority of strictures will at once begin to re-contract. 

^ The question of what constitutes the normal calibre of the urethra is 
considered in connection with diagnosis. 



ORGANIC STRICTURE OF THE URETHRA. 583 

The patient should clearly understand that unless the 
calibre of the urethra be maintained by the occasional 
use of a sound, contraction of the stricture will follow, 
and his treatment will prove of no permanent value. 

To prevent re-contraction a full-sized sound should be 
passed with sufficient frequency. At first this procedure 
should be done once in a week or ten days, then once 
in two weeks, the intervals thus being lengthened grad- 
ually until the sound is no longer needed or until it is 
discovered how long the interval may be made before 
the stricture begins to contract. A few months of such 
treatment will render further instrumentation unneces- 
sary in some cases, but usually the introduction of the 
sound must be repeated, at intervals varying from a 
week to three months, for several years, or even in- 
definitely. 

With a little instruction the patient should, as a rule, 
learn to pass the full-sized sound upon himself, thus ob- 
viating the necessity of occasional visits to the surgeon 
during long periods of time, and also lessening the prob- 
ability of neglect. The patient should be impressed 
especially with the necessity of keeping his sound clean 
and aseptic. If such a course of dilatation be faithfully 
carried out, many strictures disappear entirely, while 
others, with a little care on the part of the patient, are 
kept under control and rendered harmless. 

That absorption of the stricture-growth during a 
course of gradual dilatation actually occurs can often 
be demonstrated by watching the progress of a case in 
which the growth can be felt by the fingers on the out- 
side and its gradual disappearance be noted. 

In strictures of small calibre uncomplicated by reten- 
tion or other urgent symptoms, gradual dilatation is 



584 SYPHILIS AXD THE VENEREAL DISEASES, 

carried on as above described, except that flexible in- 
struments should be used until the stricture is dilated 
sufficiently to receive a No. 15 or 18 sound. The great 
danger of making a false passage in using a conical 
steel sound smaller than No. 15 cannot be too strongly 
impressed upon those who have never had an oppor- 
tunity to observe how easily this unfortunate accident 
can occur. Though with steel sounds progress is more 
rapid and discomfort to the patient is less, yet for all 
sizes below No. 15 or 18 soft instruments should be 
used. 

Since less dilatation is usually accompHshed at each 
sitting with the flexible bougies than with sounds, the 
resulting congestion and irritation are less and subside 
more rapidly, so that the intervals between sittings 
should be shorter. The proper interval varies from two 
to five days, and should be determined in each case in 
the same manner as when sounds are used. 

In some cases of old stricture, though the patient be 
able to pass a small stream of urine, great difficulty is 
experienced in introducing even the finest instrument. 
The opening is usually eccentric and may possibly be 
covered with a flap of mucous membrane ; or the canal 
through the stricture is tortuous and presents many 
small pockets, open follicles, or false passages (Fig. 26). 
Such strictures are often termed " impassable,"' but so 
long as a stricture has a calibre sufficient to allow the 
escape of urine, it is possible to enter it with filiform 
bougies if these be used with the proper skill, patience, 
and perseverance. The methods of using filiform bou- 
gies have already been described in detail. 

It sometimes happens that a number of prolonged 
sittings at intervals of a day or two are necessary before 



ORGANIC STRICTURE OF THE URETHRA. 585 

an instrument can be made to enter the stricture; but 
these attempts should not be given up unless there be 
retention or other urgent symptoms demanding imme- 
diate relief, or unless the use of instruments is followed 
by urethral fever or by other unfavorable result. Some- 
times the end of the bougie enters the stricture far 
enough to be grasped, but will pass no further. In 
such a case the bougie should be left in this position for 
ten or fifteen minutes, when it probably can be intro- 
duced still further. If it refuses to pass further at the 
end of half an hour, it may be tied in place and left for 
twenty-four hours, at the end of which time, if it will 
not enter the bladder, it will at least have dilated the 
anterior portion of the stricture, which will consequently 
be more readily entered by other instruments, some of 
which will eventuall}^ pass to the bladder. 

When a filiform bougie has passed a stricture after 
several unsuccessful attempts, the next step in treatment 
depends on a number of conditions. If the previous 
manipulations have caused little urethral irritation, if 
there are no symptoms demanding immediate inter- 
ference, and especially if the operator has located the 
opening of the stricture, so that he can find it readily 
at the next visit, the bougie should be left in place for 
from fifteen minutes to an hour and then be removed. 
Retention due to swelling of the mucous membrane 
may follow, but it rarely lasts for more than a few hours, 
and it can usually be relieved by a hot bath and, if neces- 
sary, by an opiate. At the end of forty-eight hours a 
large bougie can usually be passed, and treatment by 
gradual dilatation is then fairly begun. If the stricture 
is somewhat irritable, is complicated by partial or com- 
plete retention, and has been entered with great difficulty, 



586 SYPHILIS AND THE VENEREAL DISEASES. 

and especially if the urethra be sensitive to instrumen- 
tation, the best method of treatment is by continuous 
dilatation. 

Continuous dilatation is accomplished as follows : The 
first filiform bougie that passes should be tied in and 
allowed to remain for twenty- four hours. After a few 
hours the stricture dilates and allows the urine to pass 
beside the bougie, so that retention rarely occurs. At 
the end of twenty-four hours the dilatation is usually 
considerable, and the filiform may be replaced by a 
bougie a size or two larger, which may be tied in for 
another twenty-four hours. Successive sizes may thus 
be used for a few days until the stricture will admit a 
No. 8 or No. lO bougie. Further dilatation is best ac- 
complished by the gradual method. The chief objection 
to the employment of continuous dilatation is that it 
occasionally results in cystitis or produces urethral fever. 
The danger can be lessened greatly by using all anti- 
septic precautions, including irrigation of the urethra 
and the bladder, and by giving full doses of boric acid 
throughout the treatment. The new bougie or catheter 
substituted each day should be one or two sizes smaller 
than the largest that can be introduced. An instrument 
that completely fills the stricture produces more pressure 
and increases the danger of complications without pro- 
ducing more rapid dilatation than one a size or two 
smaller. Very small bougies, however, may easily be 
washed out of the urethra by the urine. The outer end 
of the bougie should be tied with two or three pieces of 
soft cotton twine to the pubic hairs. If these pieces of 
twine are also fastened to a ring (large enough to permit 
erection) of narrow tape encircling the penis an inch or 
two from the glans, the bougie will be held more 



ORGANIC STRICTURE OF THE URETHRA. 587 

securely. Unless some means be employed to secure 
the bougie, it may slip out of the urethra, or it ma}^ 
escape backward into the bladder and necessitate an 
operation for its removal. 

Continuous dilatation should not be employed in 
patients who do not tolerate well the presence of a 
bougie in the urethra, nor in patients who will not re- 
main in bed during the treatment. It should be sub- 
stituted by some other method if it is attended by 
decided urethral fever. Slight fever and chills are not 
sufficient reason for suspending treatment, but such cases 
require careful and constant w^atching. 

When continuous dilatation is not applicable to a 
given case, the first filiform bougie passed may be used 
as a guide for the introduction of a tunnelled sound or 
a catheter. The method has already been described in 
detail. If the attempt is successful, gradual dilatation 
may follow. If the tunnelled sound cannot be intro- 
duced, and if continuous dilatation is not permissible, 
urethrotomy must be performed. 

Dilatation, as previously described, is the most effec- 
tive as well as the safest method of treatment in most 
cases of stricture ; but there are not infrequently en- 
countered cases which refuse to yield to this method, 
and which may be rendered worse by attempting to 
continue it. Treatment by internal urethrotomy when 
the stricture is located in the pendulous urethra, and by 
external urethrotomy or by the combined method for 
stricture of the deep urethra, is necessary in the follow- 
ing classes: i. Most of the true strictures of the meatus. 
2. Cicatricial and traumatic strictures which refuse to 
yield to either gradual or continuous dilatation. 3. Re- 
silient strictures which rapidly re-contract after dilatation. 



588 SYPHILIS AND THE VENEREAL DISEASES. 

4. Strictures in which attempts at dilatation are followed 
b}^ marked urethral fever and chills. 5. Strictures com- 
plicated by abscess, fistulae, extravasation, or other con- 
ditions which render a perineal section necessary, the 
stricture being divided at the same operation. 6. Stric- 
tures with which retention is complete or of long stand- 
ing, or with which the general health is involved and 
immediate relief is necessary. 7. Some strictures com- 
plicated by an enlarged prostate. 8. Strictures in indi- 
viduals who cannot give the time necessary for treatment 
by dilatation. 

Many operators cut all strictures of the pendulous 
urethra, but the majority of surgeons of the present day 
cut such strictures only when they refuse to yield to 
dilatation. The cutting operation must be followed by 
the regular use of the sound if the results are to be per- 
manent, and internal urethrotomy is attended not only 
by some danger to life, but also, when the operation is 
extensive, by danger of subsequent deformity of the 
penis, rendering erections imperfect or painful and inter- 
fering wnth the expulsive power of the urethra, so that 
micturitition is followed by dribbling of urine. Many 
of the '' strictures of large calibre " which have been 
reported as cured by internal urethrotomy alone were 
undoubtedly mere normal contractions of the urethra. 
Cutting should be reserved for those strictures to which 
dilatation is not applicable. 

Mcatoioriiy. — Strictures at the meatus or just within it 
do not yield to dilatation, which in this part of the ure- 
thra is painful and irritating. Such strictures should be 
cut. Congenital narrowing of the meatus does not call 
for operation unless interfering with the normal func- 
tions of the urethra and productive of symptoms, or 



ORGANIC STRICTURE OF THE URETHRA. 589 

unless it is necessary to introduce large instruments for 
treatment of the deeper portions of the urethra. Meatot- 
omy may be performed with a straight bistoury or with 
a probe-pointed tenotome with a convex edge. The in- 
cisions should be made slowly and carefully, upon the 
floor and in the median line, until the tissue forming the 
stricture has been divided completely. In case of con- 
genital narrowing the opening, in order to allow for some 
contraction, should be made slightly wider than it is ex- 
pected to remain. When hemorrhage occurs, it can be 
controlled by pressure, and, if necessary, the glans may 
be compressed continuously by wrapping around it several 
times a narrow strip of rubber plaster. The plaster will 
have to be removed with each act of micturition, but the 
patient can easily re-apply it. Beginning the second day 
after the operation, a full-sized sound should be inserted 
once a day until healing is complete ; reunion of cut sur- 
faces is thus prevented. Treatment of the deeper por- 
tions should, if possible, be suspended during this period. 
Meatotomy rarely necessitates confining the patient to 
bed. 

Internal Urethrotomy. — This operation should be lim- 
ited to strictures within four inches of the meatus. For 
strictures of the bulbous and membranous portions ex- 
ternal urethrotomy or Harrison's combined internal and 
external operation is much safer than the internal opera- 
tion. No surgeon should perform internal urethrotomy 
of the deep urethra unless he is prepared to follow it, if 
necessary, with the external operation. 

When possible, all cutting operations upon the ure- 
thra should be preceded for two or three days by the 
internal administration of boric acid in from 10- to 20- 
grain doses four times a day. Such a course sterilizes 



590 SYPHILIS AND THE VENEREAL DISEASES. 

the urine and greatly lessens the danger of urethral 
fever and other complications. The operation should be 
immediately preceded by irrigation of the urethra with 
a saturated solution of boric acid or a i : io,ooo solu- 
tion of bichloride of mercury. In case of cystitis the 
bladder also should be irrigated. All instruments used 
should be absolutely clean and sterile. For several days 
previous to the operation instrumentation of the urethra 
should be avoided, to the end that urethral irritation may 
be reduced to a minimum. Strictures within two inches 
of the meatus, requiring but slight cutting, maybe operated 
upon without confining the patient to bed, but for deeper 
seated strictures and for those requiring extensive cut- 
ting the patient should be prepared carefully as for any 
other surgical operation, and should remain in bed for 
two or three days after its performance. 

For internal urethrotomy but three of the many instru- 
ments recommended for the purpose need be mentioned. 
In the pendulous urethra all incisions should be above, 
in the roof, and in the median line. If the stricture will 
admit a No. 5 (French) bougie, a Civiale urethrotome, 
or Gross's modification of the instrument (Fig. 41), which 



Fig. 41.— Gross's modification of Civiale's urethrotome. 

has an acorn-shaped head, is the simplest instrument. 
The bulb is passed through the stricture, the blade is ex- 
posed by a mechanism in the handle, and the instrument 
is withdrawn sufficiently to cut through the stricture 
from behind forward. The blade is then sheathed and 
the instrument is withdrawn from the urethra. A steel 
sound ■ should then be passed through the cut stricture, 



ORGANIC STRICTURE OF THE URETHRA. 59 1 

but not to the bladder, in order to ascertain if the stricture 
be divided completely. If the division is not complete, 
the urethrotome may again be introduced and the stric- 
ture be divided thoroughly. If the cutting has been at 
all extensive, it is often best to tie a full-sized soft cathe- 
ter in the urethra for the first twenty-four or forty-eight 
hours. Hemorrhage, which is not often severe, may be 
controlled by winding a strip of rubber plaster about 
the glans, as recommended after meatotomy. Twenty- 
four or forty-eight hours after the operation a full-sized 
steel sound should be passed through the stricture. 
This procedure is repeated daily for three or four days, 
and then a few times at intervals of three or four days. 
To render the result permanent, it is usually necessary 
to continue the occasional use of the sound in the same 
manner as after treatment by dilatation. 

When strictures of a calibre larger than No. 18 or 20 
require cutting, the Otis urethrotome (Fig. 42) is prob- 



FiG. 42. — Otis's dilating urethrotome (Tiemann). \^.^_^3 

ably the best instrument in use. The closed instrument 
is introduced into the urethra until the point occupied 
by the knife is half an inch behind the stricture. By 
means of a screw in the handle the parallel blades are 
separated until the stricture is put fully on the stretch ; 
the blade is then withdrawn, cutting the stricture from 
behind forward. The cutting should be followed by the 
use of sounds as above described. 

The Maisonneuve urethrotome, formerly used for in- 



592 SYPHILIS AND THE VENEREAL DISEASES. 

ternal urethrotomy in the deep urethra, is probably 
the best instrument for this purpose, since it can be 
attached to a fihform guide and thus be conducted 
through a stricture; but this operation is one to be 
avoided if possible, unless it be followed by perineal 
puncture and drainage as recommended by Harrison in 
his combined operation. Some of the modifications are 
superior to the original instrument in having protecting 




Fig. 43.— Teevan's modification of Maisonneuve's urethrotome with guide (Tiemann). 

sheaths for the knife, which can thus be made to cut the 
stricture-tissue without damaging the rest of the urethra, 
and in being fitted with a wire stylet, the removal of 
which allows the escape of urine if the instrument has 
properly entered the bladder, the danger of cutting a false 
passage being thus obviated (Fig. 43). The instrument is 
of occasional service in the anterior urethra, since, by 
means of its guide, it can be inserted into a stricture too 
narrow to admit the smallest Civiale urethrotome, and 
the stricture may then be divided partially from before 
backward. For this purpose the knife should run in a 
groove in the upper surface, in order to make the incision 
in the roof of the urethra. 

The indications for internal urethrotomy have already 
been considered. This operation should be performed 
when the stricture is situated within four inches of the 
meatus and cannot be properly treated by dilatation. 



ORGANIC STRICTURE OF THE URETHRA. 593 

External tcrctkrotojny [external perineal urethrotomy, 
perineal section) becomes necessary when stricture of the 
bulbous or membranous urethra is not amenable to treat- 
ment by dilatation, or when complications necessitate the 
immediate division of stricture. The operation should 
always be preceded by an attempt, while the patient is 
under ether, to pass a full-sized steel sound, in order that 
the possible mistake of cutting a mere spasmodic stric- 
ture may be avoided. If a filiform bougie can be passed, 
it is used as a guide in what is known as " Syme's opera- 
tion " or in the combined method of Harrison ; but when 
a filiform bougie cannot be made to enter the bladder, 
the much more difficult procedure of external perineal 
urethrotomy without a guide (generally known as 
" Wheelhouse's operation ") must be performed. 

These operations, fully described in all text-books on 
surgery, and therefore requiring no description in these 
pages, should be undertaken by none but skilled sur- 
geons. 

Divulsion of stricture in the deep urethra is practised 
by some surgeons when the patient will not consent to a 
urethrotomy, but it is a dangerous procedure. Rarely 
the method may be of advantage m the pendulous urethra, 
for the purpose of dilating a tight stricture sufficiently to 
admit a Civiale urethrotome. For this purpose a Thomp- 
son rapid dilator should be used, since it can be threaded 
on a filiform guide. 

Other methods have been recommended and employed 
at various times for the treatment of stricture, but they 
are inferior to those described. 

Complications of Stricture. — Retention. — When re- 
tention occurs suddenly, it is largely due to an added 
inflammation or irritation of the urethra, and can usually 

38 



594 SYPHILIS AND THE VENEREAL DISEASES. 

be relieved promptly by the use of the hot bath or by 
the soft catheter in the manner described for the relief 
of retention in gonorrhoea. If the patient is seen before 
the bladder is much distended, an opiate every hour may 
overcome spasm and give relief A filiform bougie can 
often be passed when attempts with a catheter fail ; if 
the bougie be left in the stricture for a few hours, the 




Fig. 44.— Suprapubic and rectal routes for the relief of retention of urine (redrawn 
from Holden). 



stricture will dilate and allow the urine to escape. 
When other measures fail, an aspirator may be used. 
Puncture of the bladder with a trocar through the 
rectum is permissible in case an aspirator cannot be 
obtained (Fig. 44). 

In old cases of tight stricture with a history of re- 
peated attacks of retention or of gradually increasing 



ORGANIC STRICTURE OF THE URETHRA. 595 

difficulty in emptying the bladder, and when the 
stream of urine is very small at best, retention is a more 
serious matter. In these cases the hot bath, an opiate, 
and even an anaesthetic, may be tried, but these 
measures are frequently ineffective. If possible, a fili- 
form bougie should be passed through the stricture, 
which may then be treated by continuous dilatation or by 
external urethrotomy. If a bougie cannot be passed, it 
is proper to relieve the bladder by aspiration for several 
days, if by so doing the instrument can eventually be 
made to enter the bladder. In case all such attempts 
fail, external urethrotomy without a guide becomes 
necessary. To determine the best method of proceeding 
the surgeon should consider carefully the character of 
the stricture, the experiences of the patient during 
previous attacks of retention, and all other conditions 
peculiar to the case. 

False Passages. — When false passages exist in connec- 
tion with stricture, they should be recognized, located, 
and avoided during treatment. Such passages are 
usually small and serve to entrap the ends of fine instru- 
ments. If the directions already given for instrumenta- 
tion of the urethra, and especially those for the use of 
filiform bougies, be followed carefully, danger of dilating 
a false passage will be avoided. The walls of old false 
passages that have been kept open sometimes undergo 
changes similar to those of stricture, and therefore will 
grip an instrument after the manner of a stricture. The 
diagnosis in these cases is difficult, and must be made 
with great care. 

False passages are produced most frequently by the 
use of small steel instruments, usually during an attempt 
to pass the instrument from the bulbous to the mem- 



596 SYPHILIS AND THE VENEREAL DISEASES. 

branous urethra. The urethral walls in front of a simple 
stricture and in the course of a tortuous stricture are 
often so thinned and softened that they may easily be 
penetrated by a small steel sound, especially if force be 
used. When a surgeon has been unfortunate enough to 
make a false passage, he should recognize the fact, or he 
may continue and dilate the opening instead of the 
stricture. The perforation of the urethral wall by the 
point of an instrument gives the hand of the operator a 
sensation very different from that produced when the 
mstrunient passes through a strictured point in the 
urethra. The instrument is obstructed in its movements, 
but is not gripped as when it has entered a stricture. 
The direction of the handle shows that the point is not 
in the median line, and if the handle be depressed, it 
cannot be rotated as when the point is in the bladder. 
The finger on the perineum or in the rectum will prob- 
ably distinguish the point of the instrument. On with- 
drawing the latter there is usually considerable hemor- 
rhage. 

The treatment of a recent false passage consists of 
rest, boric acid internally, hygiene, and the avoidance, 
if possible, of all instrumentation of the urethra for two 
or three weeks. The damaged tissue usually becomes 
inflamed, causing a discharge of blood and pus for a few 
days, but under favorable circumstances the wound heals 
in two or three weeks. Urethral fever, abscess, fistula, 
or even extravasation, may result. 

Urethral Fever {Urinary Fever). — This much-dreaded 
complication of stricture usually finds its exciting cause 
in instrumentation of the urethra. In some instances 
the urethral fever may be due chiefly to shock or to re- 
flex influences, but in most cases it is undoubtedly the 



ORGANIC STRICTURE OF THE URETHRA. 597 

result of septic infection. The urethra back of a stric- 
ture usually contains micro-organisms and their toxines 
capable of rapid absorption if the mucous membrane be 
even slightly cut, torn, or abraded, though there are 
evidences of such absorption in but a small minority of 
operations on stricture. Those cases in which nausea, 
syncope, or a chill occurs immediately after the insertion 
of an instrument into the urethra are undoubtedly due 
to nervous influence, and may result from the skilful 
passage of a smooth sound which has produced no 
damage to the mucous membrane. 

Some patients are peculiarly susceptible to chills and 
fever, which in a few individuals follow every attempt at 
urethral instrumentation. This susceptibility may sud- 
denly develop during the treatment of a stricture, or it 
may as suddenly disappear. Occasionally this complica- 
tion is one of the symptoms of a stricture, and disap- 
pears when the latter is properly treated. It occurs 
rarely after operations on the meatus, but it increases in 
frequency with the depth of the injury in the urethra, 
being most frequent after divulsion or internal ure- 
throtomy of the deep urethra. In cases of old stricture, 
especially if complicated by bladder or kidney disease, 
the danger of a fatal termination is greatly increased. 

The symptoms usually appear within twenty-four 
hours after instrumentation, frequently following the 
first urination. In typical cases there is a sharp chill, 
lasting from a few seconds to several hours, followed by 
fever of irregular duration, ranging from 100° to 106° F., 
and terminating in more or less profuse perspiration. 
The patient may be well in twenty-four hours, or a feel- 
ing of lassitude and malaise may remain for a few days. 
In very mild cases slight chills may be the only symp- 



598 SYPHILIS AND THE VENEREAL DISEASES. 

toms noticed by the patient. In severe cases the chill 
is sudden and violent and is attended by great prostra- 
tion. The skin is cold and livid, and there may be 
vomiting and profuse diarrhoea. Suppression of urine, 
uraemia, and death may occur within twenty- four or 
forty-eight hours. In yet other cases slight chills and 
mild fever may be followed by all the symptoms of 
septicaemia or of pyaemia, with a fatal termination. 

The first chill may be followed by others without 
further exciting cause, and the fever may continue in an 
intermittent or remittent form. In these cases the symp- 
toms do not conform in type and character to the first 
attack, but vary greatly. Finally, the fever may become 
chronic, and may simulate malaria except that the 
symptoms are more irregular and the disturbance of 
digestion and the impairment of nutrition are more 
marked. The persistent forms usually occur in connec- 
tion with disease of the bladder and the kidneys. 

The treatment is chiefly prophylactic. The directions 
already given for urethral instrumentation, including anti- 
septic precautions and urethral hygiene, should be fol- 
lowed carefully. Of special value in this respect is the 
use of boric acid in doses of from 10 to 20 grains four 
times a day, its administration being begun forty-eight 
hours before operating and being continued for several 
days. With some patients a chill may be prevented by 
a prolonged milk diet or by the use of morphine and 
pilocarpine just before operatmg. There is no specific 
treatment for urethral fever after its development. The 
patient should be put to bed, and free perspiration should 
be encouraged by the use of blankets, hot- water bottles, 
hot drinks, and in some cases by the administration of 
jaborandi. Further treatment is purely symptomatic. 



ORGANIC STRICTURE OF THE URETHRA. 599 

Quinine and other allied preparations are of little, if any, 
benefit. 

Fistula. — If fistulae are small , they frequently close 
when the stricture is dilated. If they are larger and 
remain open, they should be treated on surgical prin- 
ciples. 

Abscess has been considered in connection with Peri- 
urethritis. When complicating stricture of the deep 
urethra, external perineal urethrotomy is usually the best 
treatment. 

Extravasation of urine, if at all extensive, calls for 
prompt surgical treatment to secure free drainage and to 
prevent abscess, gangrene, and extensive sloughing of 
tissue. When the quantity of extravasated urine is slight, 
involving a small circumscribed region, is not enlarging, 
and is not interfering with micturition, incisions are not 
necessary. In such cases the treatment is directed mainly 
to the patient and to the stricture. Absorption of the 
extravasated fluid may be encouraged by rest and by the 
application of hot fomentations. 



GONORRHCEA IN WOMEN. 



GoNORRHCEA in women has not been studied so lon^ 
or so carefully as has the same disease in men. There 
is great diversity of opinion with reference to the fre- 
quency of its occurrence, its relation to other forms of 
inflammation of the organs involved, and the site of in- 
oculation. Bumm and some other observers believe that 
gonococci never penetrate the vaginal epithelium, and 
that when found in a vaginal discharge they come from 
the cervix or body of the uterus. Other observers find 
that a vaginitis frequently is the first evidence of gonor- 
rhoea! infection. It is certain that in the acute gonor- 
rhoea of girls and young women vaginitis is usually 
the most prominent symptom. In older women, and es- 
pecially in those who have borne children, the vagina is 
less easily inflamed, and the process is most marked in 
the endometrium of the neck and body of the uterus or 
in the urethra. In children infected as the result of 
criminal violence or by contaminated towels or other 
media, vulvitis or vulvo-vaginitis most commonly results. 
Practically there is little difference whether the site of in- 
fection be the vulva, the urethra, the vagina, or the uterine 
neck, since in the great majority of acute cases, excepting 
those of vulvitis in young children, the inflammation ex- 
tends eventually to all of these regions, and also to the 
uterus, the Fallopian tubes, the ovaries, and the peri- 
toneum. In the chronic forms the disease is most fre- 

600 



GONORRHCEA IN WOMEN. 6oi 

quent in the vaginal portion of the neck of the uterus, in 
the pelvic organs, in the urethra, and in the glands of 
Bartholin. 

In acute gonorrhoea of women the etiology, the modes 
of infection, the period of incubation, the development of 
symptoms, and the pathological changes are similar to 
those belonging to the disease in men, though the symp- 
toms (except those of pelvic inflammation) are usually 
less severe and of shorter duration. 

The disease, however, has a yet greater tendency than 
in men to become chronic. The extent of surface involved 
and the inaccessibility of portions of it favor the continua- 
tion of the process. Furthermore, Noeggerath and others 
have demonstrated that many cases of chronic gonorrhoeal 
inflammation of the pelvic organs in women develop insid- 
iously, and are never preceded by the acute form of the 
disease. Such cases are found frequently in young mar- 
ried women whose husbands, though supposing them- 
selves sound, had never fully recovered from an old gon- 
orrhoea or a chronic gleet. A large percentage of the 
subacute and chronic pelvic disorders for which women 
consult the gynecologist originate in gonorrhoeal infec- 
tion. Another important feature of the disorder in women 
is its tendency to remain latent for long periods during 
which no evidences of the disease are apparent even on 
careful examination. Such a latent and unsuspected gon- 
orrhoea may be aroused to activity by slight causes, and 
may prove a source of infection. 

Diagnosis. — The symptoms of acute gonorrhoea in 
women are those of vaginitis, urethritis, vulvitis, Bartho- 
linitis, and endometritis resulting from other causes. Fre- 
quently salpingitis, ovaritis, and peritonitis are also pres- 
ent. Full descriptions of these disorders are found in 



602 SYPHILIS AND THE VENEREAL DISEASES. 

the text-books on gynecology. Brief consideration is 
here given merely to the main points in a differential 
diagnosis between the gonorrhoeal and the non-gonor- 
rhoeal forms of inflammation. 

General Characteristics. — In general, gonorrhoeal in- 
flammation is more severe in type than other forms ; it 
usually begins with slight symptoms, which rapidly in- 
crease in intensity for a few days, remain stationary for 
about a week, and then decline ; it rarely remains limited 
to any one organ, but usually extends to several ; it shows 
a decided tendency to persist and become chronic ; there 
is often a history of exposure to infection, followed by a 
period of incubation of from three to five or more days ; 
and the discharges show the presence of gonococci. 

Vaginitis. — This condition is present in most acute 
cases of gonorrhoea, though whether any single attack 
be a true gonorrhoeal infection or merely a severe 
catarrhal inflammation induced by irritating discharges 
from the uterine neck or from the urethra it is dif- 
ficult to decide. Microscopical examination of the 
vaginal secretion is unsatisfactory, since the vagina con- 
tains many micro-organisms, including diplococci, which 
often cannot be differentiated from gonococci. The diag- 
nosis must be based chiefly upon the presence or absence 
of the general characteristics of gonorrhoeal inflamma- 
tion, including the involvement of other organs. This 
form of vaginitis, which usually lasts for three or four 
weeks, shows a marked tendency to relapse with suc- 
ceeding menstruations and other sources of local irrita- 
tion, and to persist either as diffuse chronic vaginitis or 
in localized patches of congested, swollen, and eroded 
mucous membrane. 

Urethritis. — This condition is probably present in the 



GONORRHCEA IN WOMEN. 603 

majority of cases of gonorrhoea, and, as it does not often 
occur from other causes, except those which are trau- 
matic, its demonstration furnishes fairly good evidence 
of gonorrhoeal infection. Finger thinks urethritis is 
present in practically all cases of recent infection, but 
many observers find it much less frequent. It is usually 
a mild affection, and, while it is not infrequently followed 
by cystitis, it rarely results in disease of the kidneys, as 
in men. The subjective symptoms may be so slight as 
to pass unnoticed, or there may be decided burning and 
smarting of the sensitive swollen membrane, with fre- 
quent and painful micturition, but the inflammation is 
very rarely so intense as in gonorrhoea in men. 

The orifice of the urethra is red and swollen, and 
the congested mucous membrane may protrude. With 
a finger in the vagina the urethra is felt as a firm, tender 
cord, and if the patient has not urinated for several hours 
pus may be squeezed out of the urethra. If such pus, 
unmixed with secretions from the vagina or the vulva, 
contains gonococci, the diagnosis is unmistakable. The 
acute symptoms rarely last for more than two or three 
weeks, but they are frequently followed by a chronic 
urethritis which is often overlooked. 

Chronic urethritis in women presents no subjective 
sensations, and is recognized only by careful examination. 
If the orifice be cleaned carefully and pressure be made 
upon the urethra from behind forward when the patient 
has not urinated for several hours, there can usually be 
expressed a drop of muco-pus containing gonococci. 
The endoscope may often be used to advantage. The 
many follicles of the urethra may be involved, thus favor- 
ing the continuation of the disease. Five or six large 
follicles near the orifice are of especial importance, and 



6o4 SYPHILIS AND THE VENEREAL DISEASES. 

should be examined carefully, as the inflammation may 
be limited to them. Chronic urethritis in women is more 
easily cured than in men, but is quite commonly unrecog- 
nized and untreated. 

Vulvitis. — In adults vulvitis has not yet been demon- 
strated to be gonorrhoeal in character. The inflammation 
simply results from contact of the surfaces with irritating 
discharges from the vagina and the urethra. This con- 
dition in women corresponds with balanitis in men. In 
children, however, gonorrhoeal inflammation of the vulva 
has been demonstrated, though these cases have no cha- 
racteristic features that will serve to distinguish them 
from vulvitis due to other causes. 

Bartholinitis. — Inflammation of the vulvo-vaginal 
glands finds its most frequent cause in gonorrhoea, and 
when due to such infection usually runs a rapid course 
and terminates in suppuration. An acute infection is 
rarely, if ever, limited to the gland. 

Chronic inflammation of these glands not infrequently 
complicates chronic gonorrhoea, and may survive as the 
sole relic of the original disease. The affected gland is 
usually recognized as a firm, painless nodule; its duct 
is dilated and reddened. Pressure on the gland usually 
causes the escape of a mucous or muco-purulent dis- 
charge which may contain gonococci and may prove 
highly infectious. 

Inflammation of the Uterus and its Appendages. — Endo- 
metritis of the uterine neck occurs in most cases of acute 
gonorrhoea, and in a large percentage of cases the disease 
extends to the tubes, the ovaries, and the peritoneum. 
The origin of the inflammation in these organs cannot 
be determined by the symptoms alone, but is recognized 
by the presence of other evidences of gonorrhoea and by 



GONORRHCEA IN WOMEN. 605 

the history. That the gonococcus is an active factor in 
the production of these pelvic inflammations is apparent 
from the fact that this micro-organism has been found in 
the pus of pyosalpinx and in the epithelium and connec- 
tive tissue of the Fallopian tubes. 

In chronic gonorrhoea the inflammation almost always 
involves the pelvic organs, and is one of the most fre- 
quent causes of sterility and of chronic invalidism in 
women. 

The frequency with which a chronic gonorrhoeal in- 
flammation may remain latent and confined to one or 
more follicles of the urethra, to one of the vulvo-vaginal 
glands, or to the cervix or body of the uterus readily 
explains why a man may be infected from coitus with a 
woman who shows no signs of the disease, and also why 
he may have intercourse with her many times before 
coming in contact with the gonorrhoeal virus. 

Treatment. — Hygienic treatment, which is always of 
great importance, is practically that of gonorrhoea in 
men. Rest, a light diet, diluent drinks, and frequent 
washing of the external genitals should be secured. If 
urethritis is present, and micturition is painful, alkalies 
and the balsams should be given. All discharges should 
be caught on pads of cotton held in position by a band- 
age, and these pads should be burned when soiled. At 
first, if the vaginitis be severe, local treatment must be 
postponed until the parts are less sensitive. In the mean 
time rest and the application of cold or heat, as is most 
grateful, to the perineal and pubic regions is of value. 
As soon as the patient can tolerate it, the vagina should 
be irrigated thoroughly twice daily with hot solutions of 
boric acid. The external parts should be kept clean, 
dusted with a simple powder, and covered with thin 



6o6 SYPHILIS AND THE VENEREAL DISEASES. 

layers of cotton or lint to prevent contact of surfaces. 
These measures will obviate the danger of vulvitis and 
will add to the patient's comfort. If vulvitis occur, 
slightly astringent lotions or powders may be used in 
addition. 

As the inflammation subsides it is sometimes well to 
irrigate with a solution containing I per cent, of nitrate 
of silver or i to 2 per cent, of permanganate of potas- 
sium instead of boric acid ; or somewhat stronger so- 
lutions may be applied with a brush or a cotton swab. 
The cervical canal should be kept clean and should re- 
ceive a daily application of a solution of nitrate of silver 
(3SS-5J ad f ij). Following these astringent applications 
the vagina may be tamponed with cotton soaked in 
iodoform glycerin, borated glycerin, or glycerite of 
tannin. 

If the urethritis tend to become chronic, injections 
such as those recommended for use in subacute gonor- 
rhoea in men may be used, the bladder always being 
moderately full. Later, solutions of nitrate of silver in 
gradually increasing strength may be applied through 
an endoscopic tube. If the follicles are involved, they 
should be destroyed with the fine point of a Paquelin 
cautery, or with caustic or acid. 

Acute Bartholinitis should be treated by rest and by 
hot local applications. If suppuration occur, the abscess 
should be opened and treated on surgical principles. In 
chronic Bartholinitis the gland should be enucleated or 
be destroyed by the cautery. 

The treatment of gonorrhceal inflammation of the 
uterus and its appendages should be left to the skilled 
gynecologist. 



INDEX 



Absence of subjective sensations in 

syphilis, 76 
Accidents and injuries in syphilis, 71 
"Acclimatization," 371 
Acquired syphilis, 27 

infantile, 283 
Adenitis, gonorrhoeal, 460 
Adenopathy of syphilis, 32 

syphilitic, primary, 319 
Alcohol in syphilis, 227 
Alopecia, syphilitic, treatment, 265 
with structural changes, 134 
without obvious structural 
change, 133 
syphilitica, diagnosis, 135 
Ano-rectal syphiloma, 177 
Antiquity of venereal diseases, 20 
Anus in hereditary syphilis, 223 

syphilis of, 175 
Aponeuroses, syphilis of, 167 
Ardor urinae, 376, 406 
Arterio-sclerosis, 170 
Atrophic tubercular syphiloderm, 

"3 

Atrophy of optic nerve, 202 

" Bad disorder," 27 
Balanitis, 46, 331 

diagnosis, 321, 332 

etiology, 331 

symptoms, 331 

treatment, ^^;^ 
Balano-posthitis, 331 
Bartholinitis, gonorrhoeal, 604 
Bastard gonorrhoea, 372, 38 1 

diagnostic table, 387 
Bathing, 228 

Benignant syphihs, 60, 6l 
Bestiality, 356 
Blennorrhagia, 360 



Blennorrhagie, 360 
Blennorrhoea, 360 
Blood in syphilis, 28 
Blood-vessels, syphilis of, 170 
" Blue-ball," 309 

Bones in hereditary syphilis, 216, 
223 

in syphilis, treatment, 270 

syphilis of, 159 
Boubon^ 309 
Bougie a boule, 563 
Bougies, bulbous, 563 

flexible, 564 

soft, 564 
Brain, syphilis of, 188 
Bronchi in hereditary syphiUs, 221 

syphilis of, 158 
Bubo, etiology, 312 

gonorrhoeal, 460 

of chancre, diagnosis, 319 

of chancroid, 309 

syphihtic, 32 
treatment, 56 
Bulbous bougies, 563 
Bursse, syphilis of, 166 

Cachexia, syphilitic, 70 
Calcareous lesions of hereditary syph- 
ihs, 211 
Calibre of the urethra, 577 
Care of instruments, 570 
Catarrh of middle ear, 204 
Catheterism of the urethra, 556 
Catheters, silver, 564 

soft, 565 
Central recurrent retinitis, 20I 
Cerebro-spinal syphilis, 192 
Chancre, 30 

deeply ulcerating, 36 

diagnosis, 45, 316 

607 



6o8 



INDEX. 



Chancre, duration of, 43 

extra-genital, 40 

hard, 30 

Hunterian, 36 

infecting, 30 

in women, 39 

location, 39 

"mixed," 36, 305 

pathological anatomy, 51 

soft, 37 

superficially ulcerating, 36 

termination of, 43 

treatment, 51 

urethral, 39 

vaginal, 40 
Chancre mou, 293 
Chancre syphilitique, 30 
Ckancrelle, 36, 293 
Chancres, induration of, 41 

number, 41 

of the syphilized, 38 

portent of, 43 , 

within the nares, 153 
Chancroid, 36, 45, 293 

adenopathy, 309 

and paraphimosis, 306 

and phagedena, 307 

and phimosis, 306 

auto-inoculability of secretion, 303 

complications, 305 

diagnosis, 314, 316 

duration, 300 

erosive lesion, 298 

etiology, 294 

extra-genital, 305 

gangrene, 309 

incubation, 301 

induration, absent, 302 

lesions, 297 

location, 304 

lymphadenitis, 309 

lymphangitis, 309 

number of, 299 

pustular lesion, 297 

size, 300 

subjective sensations, 302 

treatment, 322 

variations, 299 

with vegetations, 305 
Chancroidal bubo, 309 
diagnosis, 318 



Chancroidal bubo, etiology, 312 

treatment, 328 
Chaudepisse, 360 

Chemical causes of urethritis, 370 
Chordee, 377 

treatment, 407 
Chorio-retinitis, 2(X) 
Cicatrices from gummata, 124 
Ciliary body, syphilis of, 199 
Clap, 360 

Classification of syphilodermata, 81 
Cold sound in urethritis, 518 
Colles's law, 206, 207 
Color in syphilodermata, 75 
Color-test for shreds in urine, 497 
Complications of urethritis, 417 
Condensing osteitis, 162 
Condyloma, 47, loi 
Condylomata lata, 1 01 
Congenital syphilis, 205 
Conjunctiva, syphilis of, 196 
Conjunctivitis, gonorrhoeal, 470 

diagnosis, 473 

etiology, 471 

pathology, 473 

prognosis, 479 

symptoms, 471 

treatment, 474 
Continuous immersion in chancroids, 

326 
Copaiba-rash, 401 
" Copper color," 75 
Cord, syphilis of, 191 
Cornea, syphilis of, 196 
Corneous syphiloderm, 99 
Corona veneris, 91 
Corymbiform syphiloderm, 94 
Cowperitis, 459 

Cranial bones in hereditary syphilis, 
223 
meninges, syphilis of, 188 
Crystalline lens, syphilis of, 200 
Curve of the urethra, 554 
Cystitis, gonorrhoeal, 450 

causes, 450 

diagnosis, 452 

symptoms, 451 

treatment, 454 

Dactylitis, syphilitic, 163 
hereditary, 218 



INDEX. 



609 



" Defective memory," 349 
Delire des grandetirs, 193 
Dementia paralytica, 192, 193 
Diagnosis of chancre, 316 

of chancroid, 316 
Disinchuation for society, 349 
Dreams, 349 

"Dry" tubercular syphiloderm, 113 
Ducrey, micro-organism of, in chan- 
croid, 313 

Ear in hereditary syphilis, 226 

in syphilis, treatment, 276 

syphilis of, 203 
Eburnation, 162 
Eczema of genital region, diagnosis, 

321 
Emfacher Schanker, 293 
Endarteritis obliterans, 170 
Endoscope in urethritis, 499 
Endoscopic urethral instruments and 

methods, 500 
Epididymis, syphilis of, 181 
Epididymitis, acute, 422 
symptoms, 427 
treatment, 436 

chronic, symptoms, 427 
treatment, 436 

diagnosis, 428 

etiology, 422 

frequency, 422 

prognosis, 436 

relapses, 426 

strapping the testicle in, 433 

symptoms, 423 

syphilitic, treatment, 273 

treatment, 428 
Epithelioma, genital, 48 

of genital region, 321 
Erosion, 2,2) 

superficial, 33 
Erotomania, 356 
Erythematous syphiloderm, 85 
Esthioviene, 176, 308 

of Huguier, 184 
Evolution of syphilis after chancre, 
66 

of syphilodermata, 77 
Excursions of syphilis, 57 
Extravasation of urine due to stric- 
ture, 550, 599 

39 



Eye in hereditary syphilis, 225 
in syphilis, treatment, 275 
syphilis of, 194 

Eyelids, syphilis of, 195 

Failure of erection, 353 
Family, the, and syphilis, 284 
Fever, syphilitic, 68 

urethral, 562 
Fibrosis of kidney, 186 
Filiform bougies, 565 

introduction of, 568 
Finger, syphilitic, 163 
Fistula, 599 

of the urethra due to stricture, 550 
Flexible and steel instruments com- 
pared, 569 
bougies, 564 
Formative osteitis, 161 
Fractures in bone-syphilis, heredi- 
tary, 217 
Frequency of micturition in stric- 
ture, 544 
Fumigation with mercury, 243 

Galloping syphilis, 59 
Gangrene and chancroid, 309 
Gastro-intestinal tract, syphilis of, 173 
Gauge, Handerson's, 563 
General considerations, etc., relative 

to syphilodermata, 79 
Genital organs in hereditary syphilis, 

215 

Genito-urinary organs, syphilis of, 
181 
in men, 181 
in women, 183 
Glands, lymphatic, 69 
Gleet, 360, 483 

due to stricture, 546 
Glossite tonsurante, 147 
Goinnie scrofuleuse, 125 
Gonococcus, 362 
characters, 365 
culture of, 366 
etiological factor in gonorrhoea, 

cause of, 362 
in chronic urethritis, 486, 489, 491 
preparation of specimen, 362, 388 
value in diagnosis, 366, 388 
Gonorrhee, 360 



6io 



INDEX. 



GoJiorr/ioe, 360 
Gonorrhoea, acute, 360 
bastard, 372, 381, 387 
cause of pelvic inflammation in 

women, 492 
chordee in, 377 
chronic, 483 
compHcations, 417 

adenitis, 460 

conjunctivitis, 470 

Cowperitis, 459 

cystitis, 450 

epididymitis, 422 

folUculitis, 456 

infection of mouth and rectum, 
481 

lymphangitis, 460 

ophthalmia neonatorum, 479 

periurethritis, 457 

posterior urethritis, 417 

prostatitis, 437 

pyelitis, 454 

rheumatism, 461 

vesiculitis, 448 
definition, 360 
diagnosis, 383 

differential, 385 

examination of patient, 383 
diagnostic table, 387 
diagnostic value of gonococcus, 366 
differential diagnosis, 385 
epididymitis from, 422 
exammation of discharge, 388 
folliculitis in, 456 
in women, 600 

diagnosis, 601 

treatment, 605 

unrecognized, 605 
lymphangitis in, 378 
microscopical examination of dis- 
charge, 388 
most venereal of diseases, 361 
pathology, 381 
prognosis, 414 
relapse, 379 
sexual hygiene, 397 
symptoms, constitutional, 378 

increasing stage, 375 

prodromal stage, 375 

stage of decline, 378 

stage of incubation, 374 



Gonorrhoea, symptoms, stationary 
stage, 378 
variations in, 379 
table of differential diagnosis, 387 
treatment, 389 
abortive, 391 
by stages, 405 
dressing for penis, 398 
general conditions, 390 
hygiene, 395 
beverages, 396 
diet, 396 
dressings, 397 
rest, 396 

sexual hygiene, 397 
tobacco, 397 
injections, 409 

in early stages, 393 
internal, 400 

irrigation in early stages, 392 
of chordee, 407 
of retention of urine, 407 
of sexual irritation, 407 
prophylaxis, 389 
suspensory bandages, 399 
unrecognized, 373 
Gonorrhceal conjunctivitis, 470 
rheumatic ophthalmia, 467, 474 
rheumatism, 461 
diagnosis, 468 
etiology, 461 
of bursse, 466 
of synovial sheaths, 465 
ophthalmic symptoms, 466 
pathology, 467 
prognosis, 470 
symptoms, 462 
treatment, 469 
varieties, 463 
Gram's method of staining the gono- 
coccus, 364 
" Ground-glass " cornea, 226 
Gumma, 121 
Gummata of mouth, 149 
of rectum, 177 
treatment, 272 
Gummatous fibrosis of lung, 172 
iritis, 198 
syphiloderm, 121 
diagnosis, 125 
pathology, 127 



INDEX. 



6l 



Hair, syphilitic affections of, 133 
Hairs in hereditary syphihs, 215 
Handerson's gauge, 563 
Hard chancre, 30 
Hartes Gesc/nviir, 30 
Heart, aneurysm of, 169 

syphihs of, 168 
Herpes progenitalis, 46, 344 

diagnosis, 320, 345 

symptoms, 344 

treatment, 346 
History of venereal diseases, 20 
Hunterian chancre, 36 
Husband, infected, 285 
Hutchinson's teeth, 219 
Hydrargyrism, 250 
Hygiene of syphilis, 227 

of urethra, 395 
Hyperostoses of tibia, 217 
Hypochondriasis, 347 

treatment, 358 
Hypodermatic injection of mercury, 
245 

Immunity against syphilitic mfec- 

tion, 30 
" Impotence," 349, 355 
Incubation of chancre, first, 31 
second, 69 

of chancroid, 301 
Indurated papule, 35 
Infantile syphilis, acquired, 283 
Infecting chancre, 30 
Infection of husband, 285 

of physicians, 19 

of wife, 285 
Infectious urethritis, 360 
Infiltration of urine, 550 
Inherited syphilis, 205 
Initial lesion, 30 

sclerosis, 30 
diagnosis, 316 
Injection of chancroidal buboes, 329 

of deep urethra, 519 

of mercury, hypodermatic, 245 
Injections in gonorrhoea, 409 

in urethritis, 511 
Injuries and accidents in syphilis, 71 
Insoluble salts of mercury for injec- 
tion, 249 
Instrumentation of the urethra, 553 



Instrumentation of the urethra, indi- 
cations for, 572 
urethral spasm in, 529 
with flexible instruments, 567 
Instruments, care of, 570 

list of those needed, 571 

urethral, 562 
Insurance of the infected, 289 
Internal urethrotomy, 589 
Interstitial keratitis, 196 
Intestinal tract in hereditary syph- 
ilis, 222 
Introduction, 17 
Inunction of mercury, 238 
Iodides in hereditary syphilis, 279 
Iodine and its compounds, 252 

compounds, toxic effects, 257 
Iris, syphilis of, 197 
Iritis, gummatous, 198 

serous, 198 

syphilitic, treatment, 275 
Irrigation of urethra, 496, 512 

Joints, syphilis of, 165 

Keratitis, interstitial, 196 
Keyes-Ultzmann syringe, 519 
Kidney, syphilis of, 185 
Kidneys in hereditary syphilis, 232 
Kiefer's urethral irrigation nozzle, 

497 
ICrankheit der Franzosen, 27 

Labyrinth in syphilis, 205 
Labyrinthitis of hereditary syphilis, 

226 
Lachrymal gland, syphilis of, 194 
Langiiettes, 180, 184 
Larynx in hereditary syphilis,, 221 
syphilis of, 155 

prognosis, 158 
Lassar paste, 243 
Latent gonorrhoea in women, 605 
Legal sanction of prostitution, 290 
Leptomeningitis, 224 
Lesions of chancroid, 297 
Leucokeratosis, lingual, 147 
Leucoma buccse, 147 
Leucoplasia of the mouth, 147 

diagnosis, 150 

patholog)', 152 



6l2 



INDEX. 



Lichen planus, genital, 49 
Life-assurance societies and syphilis, 

289 
"Ivightning" symptoms, 64 
Lipoma, 126 
" Listerine," 267 
Liver in hereditary syphilis, 222 

syphilis of, 173 
Loss of memory, 354 
"Losses at stool," 351 
" Lost manhood," 349, 354 
Lues venerea, 27 
Lung, gummatous fibrosis of, 172 
Lungs in hereditary syphilis, 221 

syphilis of, 171 
Lung-syphilis, diagnosis of, 172 
Lupoma, 125 
Lupus of the vulva, 176 
Lustseiiche, 27 

Lymphadenitis and chancroid, 309 
Lymphangitis and chancroid, 309 

in gonorrhoea, 378 
Lymphatic glands, 69 

in hereditary syphilis, 215 

Macular syphilis of mouth, 143 

syphiloderm, anatomy, 89 
diagnosis, 89 

syphilodermata, 82 
Malignant syphilis, 62, 63 
Mammaha, sexual relations of, 347 
Marriage after syphilis, 287 
Masochism, 356 
Masturbation, 349 
" McDade formula," 256 
Meatotomy, 517, 588 

indications for, 576 

results of, 576 
Mechanical causes of urethritis, 369 
Melanotic Mdiitlow, 164 
Membrana tympani, 204 
Meninges, syphilis of, 191 
Mental states due to syphilis, 192 
Mercier catheter, 565 
Mercurial inunctions m hereditary 
syphilis, 280 

pains, 250 
Mercury by fumigation, 243 

by injection, 245 

by inunction, 238 

in syphilis, 232 



Mercury, toxic effects of, 250 
Method of examining patients, 22 
Miliary papules, 92 

pustular syphiloderm, 105 
Mixed chancre, 36, 305 
" Mixed treatment," 259 
Modes of infection in syphilis, 29 
Moist papule, 100, 144 
diagnosis, 103 

wart, 47, 10 1 
Molluscum epitheliale, 48 
Monti's formula, 279 
Morbus gallicus, 27 
Mouth, gummata of, 149 

leucoplasia of, 147 

macular syphilis of, 143 

smoker's patches of, 147 

syphilis of, 142 
Mucous membranes in hereditary 
syphilis, 214 

patches, 100, 145 

plaques, 100 

tubercle, 144 
Multiformity in syphilis, 76 
Multiple cerebro-spinal syphilis, 192 
Muscse volitantes, 354 
Muscles, syphilis of, 167 
Myositis, 167 

progressive ossifying, 168 

Nail, changes in, 139 
atrophic, 139 
hypertrophic, 139 
in tissues surrounding, 137 
separation of, 140 
syphilis of, diagnosis, 141 
syphilitic affections of, 136 
Nails in hereditary syphihs, 215 

syphilitic, treatment, 270 
Nasal passages in hereditary syphilis, 
219 
syphilis of, 152 
Naso-pharynx in syphilis, treatment, 

276 
Nervous syphilis, treatment, 273 

system, syphilis of, 187 
Night losses, 349 
Nocturnal emissions, 349 

pains, 160 
Nodes, 161 
Non-infecting chancre, 293 



INDEX. 



613 



Non-infectious urethritis, 369 

etiology, 369 
Nummular syphiloderm, 94 

Ocular appendages, syphilis of, 194 

muscles, syphilis of, 202 
Oculo-molor paralyses, 190 
Oculo-motorius, paralysis of, 190 
Q^lsophagus in hereditary syphilis, 

222 
Onychauxis, syphilitic, 139 
Onychia syphilitica, 139 
Ophthalmia, gonorrhoeal rheumatic, 

467, 474 

neonatorum, 479 
Optic nerve, atrophy of, 202 

syphilis of, 201 
Orbit, syphilis of, 203 
Orchitis, syphilitic, 182 
Osteitis, condensing, 162 

formative, 162 

rarefying, 161 
Otis's urethrometer, 564 
Ozsena, 153 

Pain in bone-syphilis, 160 
Palmar syphiloderm, 96 

diagnosis, 99 
Panaris, 163 

Pancreas, syphilis of, 175 
Papillitis, 201 
Papular syphiloderm, diagnosis, 93 

prognosis, 93 
Papule chancre, 35 
dry, scaling, 35 
Papules, 90 

dry, 92 

lenticular, 93 

miliary, 92 

moist, 100 
Papulo-squamous syphiloderm, 95 
Paraphimosis, 2,Z^ 

and chancroid, 306 

reduction of, 340 

symptoms, 338 

treatment, 339 
Paronychia, 136 

syphilitica, 137 
Patches, mucous, 100 
Pederasty, 356 
"Pemphigus, syphilitic," 211 



Perineal section, 593 
Periodicity in seminal losses, 350 
Periostitis, syphilitic, treatment, 271 
Peripheral nerves, syphilis of, 193 
Phagedena and chancroid, 307 
Pharynx in hereditary syphilis, 220 

in syphilis, treatment, 269 

syphilis of, 154 
Phimosis, 334 

and chancroid, 306 
treatment, 328 

diagnosis, 336 

symptoms, 335 

treatment, 336 
Physical examination of patients, 23 
Physician, duty of, respecting syph- 
ilis in the family, 284 
Physiology of generative organs, 347 
Pigmentary syphiloderm, 82 
Placenta, syphilis of, 209 
Plantar syphiloderm, 96 
Plaque miiquciise, 144 
Plaques, mucous, 100 
Plaques nniqiteuses, 1 00 
Pneumonia, syphilitic, 172 
Pointed wart, 102 
Pollutions, 351 

Polymorphism in syphilis, 76 
Posterior urethritis, 417 
Pox, 27 
Precautions required by physicians, 

. ^9 
Precocious syphilis, 59 
Pregnancy in syphilis, treatment, 277 
Premature ejaculation of semen, 353 
Primary syphilis, 58 
Progressive ossifying myositis, 168 
Proliferating syphilitic rectitis, 180 
Prostatitis, acute, 437 

abscess in, 440 

causes, 437 

constitutional disturbances in, 

439 
diffuse, 438 
follicular, 438 
parenchymatous, 438 
treatment, 441 
chronic, 443 
follicular, 443 
parenchymatous, 444 
prognosis, 448 



6i4 



INDEX. 



Prostatitis, chronic, symptoms, 443 

treatment, 446 
Prostatorrhoea, 443 
Prostitution and syphilis, 290 

regulation of, by law, 290 
Pseudo-gonorrhoea, 368 
Pseudo paralysis of hereditary syph- 
ilis, 217 
Psoriasis linguae, 147 
of genital regions, 50 

diagnosis, 321 
syphilitic, 96 
Purpuric syphiloderm, 88 
Pustular syphiloderm, diagnosis, 
III 
miliaKy, 105 
pathology, 112 
syphilodermata, 104 
Pustulo-crustaceous syphiloderm, 108 
Pustulo-ulcerative syphiloderm, 108 
Pyelitis from gonorrhoea, 454 
diagnosis, 455 
symptoms, 454 
treatment, 455 

Radezyge, 27 

Rarefying osteitis, 161 

Raw-ham color, 75 

Rectal stricture, syphilitic, treatment, 
272 

Rectite proliferante svphilitique, 
180 

Rectitis, proliferating, syphilitic, 180 

Rectum, gummata of, 177 
in hereditary syphilis, 223 
in syphilis, treatment, 272 
syphilis of, 175 

Relapses in gonorrhoea, 379 

Resolutive tubercular syphiloderm, 

"3 

Respiratory tract, syphilis of, 152 
Retention of urine due to stricture, 

593 

in stricture, 547 

treatment, 407 
Retina, syphilis of, 200 
Retinitis, central recurrent, 201 
Rheumatism, gonorrhoeal, 461 
Rhinitis, syphilitic, 153 
Roseola syphilitica, 85 
Rupia, 109 



"Sabre-blade deformity" in he- 
reditary syphilis, 216 
Sadism, 356 

vSafeguard against syphilis, 292 
Salivation, 250 
Sapphism, 356 
Satyriasis, 356 
Scabies of genital region, diagnosis, 

321 
Scale for urethral instruments, 562 
American, 562 
English, 562 
French, 562 
Scaly patches of mouth, 147 
Schanker, 30 
Schleifiijluss, 360 
Sciatica, syphilitic, 193 
Sclerotic, syphiUs of, 197 
Secondary syphilis, 58 
Serpiginous syphiloderm, 128 

diagnosis, 130 
Sexual debility, 349 

indulgence after infection, 289 
after syphilitic infection, 287 

psychopathy, 356 

weakness, 353 
Sheath, tendinous, syphilis of, 166 
Sifilide, 27 
Sifilis, 27 

Silver catheters, 564 
Simple chancre, 293 
Situation of syphilodermata, 77 
Skin in syphilis, 73 
Smoker's patches, 147 
"Snuffles," 214 
Society and syphilis, 284 
Soft chancre, 37, 293 
Soluble salts of mercury for injec- 
tion, 247 
Sounding the urethra, 556 
Sounds, steel, 562 
Spermatic cord, syphilis of, 181 
Spermatozoa in urine, 352 
Spizen Wixrzen, loi 
Spleen in hereditary syphilis, 223 

syphilis of, 175 
Stages of syphilis, 58 
Stains for the gonococcus, 363 
Steel and flexible instruments com- 
pared, 569 

sounds, 562 



INDEX. 



615 



Steel sounds, short, 563 
Stomach in hereditary syphilis, 222 
Strapping the testicle, method of, 433 
Stricture, annular, 534 

complications, 593 

constitutional symptoms, 549 

continuous dilatation, 586 

definition, 534 

diagnosis, 572 

discharge of, 546 

divulsion, 593 

duration of treatment, 582 

extravasation in, 550, 599 

false passage in, 595 

filiform bougies in, 568 
' fistuln, 550 

frequency of sittings, 580 

gradual dilatation, 578 

irritable, 536 

linear, 534 

of large calibre, 535, 579 

of small calibre, 535, 583 

of the rectum, syphilitic, 177 
treatment, 272 

of the urethra, 526 

changes in bladder and kidneys, 

453 
in the urethra, 542 

congenital, 531 

etiology, 538 

lesion in, 540 

location, 537 

number, 537 

opening in, 541 

organic, 534 

pathology, 540 

resilient, 536 

results, 544 

retention in, 593 

sexual disturbances, 549 

spasmodic, 527 

symptoms, 544 

time required for development, 
538 

tortuous, 534 

traumatic, 539 

urethral fever in, 596 

varieties, 534 
Suspensory bandages, 399 
Symmetry in syphilodermata, 75 
Synonyms of syphilis, 27 



Syphilides, 73 

Syphilis, accidents and injuries in, 

71 

acquired, 27 

infantile, 283 
and marriage, 286 
and prostitution, 290 
benignant, 60, 61 
cerebro-spinal, 192 
congenital, 205 
etiology, 27 

evolution of, in stages, 57 
galloping, 59 
germ of, 28 
hereditary, 205 

anus in, 223 

bones in, 2l6 

bronchi in, 221 

cranial bones in, 223 

cutaneous lesions in, 211 

diagnosis, 212 

ear in, 226 

etiology, 205 

eye in, 225 

genital organs in, 215 

glands in, 215 

hairs in, 215 

intestinal tract in, 222 

larynx in, 221 

liver in, 222 

lungs in, 221 

lymphatics in, 215 

mucous membranes in, 215 

nails in, 215 

nasal passages in, 219 

nervous system in, 223 

oesophagus in, 222 

pathology, 210 

pharynx in, 220 

rectum in, 223 

" sabre-blade " deformity in, 216 

skin-lesions in, 211 
bullous, 213 
hemorrhagic, 215 
macular, 212 
papular, 212 
tubercular, 215 

spleen in, 223 

stomach in, 222 

symptoms, 210 

teeth in, 220 



6i6 



INDEX. 



Syphilis, hereditary, trachea in, 22] 

treatment, 277 
inunctions in, 281 
hygiene, 227 
inherited, 205 
in relation with the family, 284 

with society, 284 
malignant, 62, 63 
of bones, 159 

diagnosis, 163 

pathology, 161 
of bony walls of orbit, 203 
of brain, 188 
of bronchi, 158 
of ciliary body, 199 
of cranial meninges, 188 
of crystalline lens, 200 
of ear, 203 
of epididymis, 181 
of eye, 194 
of eyelids, 195 
of gastro-intestinal tract, 173 
of kidney, 185 
of labyrinth, 205 
of liver, 173 

of ocular appendages, 194 
of ocular muscles, 202 
of optic nerve, 201 
of placenta, 209 
of retina, 200 
of the anus, 175 
of the aponeuroses, 167 
of the blood-vessels, 170 
of the bones, treatment, 270 
of the bronchi, 158 
of the bursse, 166 
of the choroid, 200 
of the cord, 191 
of the ear, treatment, 276 
of the eye, treatment, 275 
of the fingers, 163 
of the genito-urinary organs, 181 
in men, 181 
in women, 183 
of the heart, 168 
of the iris, 197 
of the joints, 165 

diagnosis, 166 

pathology, 165 
of the larynx, 155 

diagnosis, 157 



Syphilis of the larynx, prognosis, 158 

of the lungs, 171 

of the meninges, 191 

of the mouth, 142 
treatment, 266 

of the muscles, 167 

of the nails, treatment, 270 

of the nervous system, 187 

of the nose, treatment, 268 

of the pancreas, 175 

of the peripheral nerves, 193 

of the phaiynx, 154 
treatment, 269 

of the rectum, 175 

of the respiratory tract, 152 

of the sclerotic, 197 

of the skin, 73 

of the spermatic cord, 181 

of the spleen, 175 

of the tendons and tendinous 
sheaths, 166 

of the testes, 182 

of the third generation, 208 

of the tongue, 142 

of the trachea, 158 

of the vagina, 184 

of the vitreous humor, 200 

precocious, 59 

prophylaxis of, 292 

tardy, 59 

treatment, 227 
Syphilitic affections of the hair, 133 
of the nail, 136 

alopecia with structural changes, 

134 
without obvious structural 

change, 133 
bubo, 319 
cachexia, 70 
chancre, 30 
dactylitis, 163 
ervthema, 85 
fever, 68 

lesions, treatment, 260 
lupus, 82 
mothers, 206 
onychauxis, 139 
panaris, 163 
papules, 90 
pemphigus, 211 
pneumonia, 172 



INDEX. 



617 



Syphilitic psoriasis, 82, 96 

roseola, 85 

sciatica, 193 

snuffles, 214 

stricture of rectum, 177 

tubercles, 112 

urethritis, 368 
Syphiloderm, atrophic, 113 

corneous, 99 

corymbiform, 94 

dry, 113 

gummatous, 121 

miliary, pustular, 105 

nummular, 94 

purpuric, 88 

pustulo-crustaceous, 108 

pustulo-ulcerative, 108 

resolutive tubercular, 113 

serpiginous, 128 

tubercular, 112 

ulcerative tubercular, 115 

vegetating, 131 
Syphiloderma, 73 

palmar, 96 

plantar, 96 
Syphilodermata, characteristics of, 75 

classification, 81 

general features of, 74 

macular, 82 

pigmentary, 82 

pustular, 104 
Syphilophobia, 356 

Tabes and syphilis, 191 

Table of diagnostic distinctions be- 
tween chancroid, chancre, 
etc., 316 

Tardy syphilis, 59 

Teeth in hereditary syphilis, 220 

Tendons, syphilis of, 166 

Tertiary syphilis, 58 

Tobacco, 228 

Tongue, syphilis of, 142 

Trachea in hereditary syphilis, 221 
syphilis of, 158 

Treatment, external, 231 
internal, 231 

of chancroidal bubo, 328 
of chancroids with phimosis, 328 
of complications of chancroid, 327 
of hereditary syphiHs, 277 



Treatment of nervous syphilis, 273 
of rectal stricture in syphilis, 272 
of rectum in syphilis, 272 
of syphilis, 227 

during pregnancy, 277 
" expectant," 232 
"interrupted," 232 
of the bones, 270 
of the ear, 276 
of the nose, 268 
of the skin, 261 
systemic, 231 
time for beginning, 229 
time required for, 231 
"tonic," 231 
of syphilitic alopecia, 265 
of syphilitic epididymitis, 273 
of syphilitic iritis, 275 
of syphilitic lesions, 260 
of viscera in syphilis, 271 
Tribadism, 356 
Tripper, 360 
Tripper fad en, 495 
Tubercles, syphilitic, 112 
Tubercular syphiloderm, 112 
diagnosis, 118 
ulcerative syphiloderm, 115 
Tuberculous urethritis, 368 
Tunnelled sounds and catheters, 566 
Two-glass method, 495 

test, 419 
Tympanum, 204 

Ulcerative tubercular syphilo- 
derm, 115 
Ulcer-chancre, 35 
Unrecognized gonorrhoea, 373 
Unreiner Fluss, 360 
Urethral calibre, 577 

chancres, 39 

curve, 554 

fever, 596 

folliculitis, 456 

hygiene, 395 
Urethritis, acute, 360 

causes other than gonorrhoeal, 

369 

etiology, 360 

treatment, general considera- 
tions, 390 
of different forms, 390 



6i8 



INDEX. 



Urethritis, chronic, 483 

diagnosis, 490 

etiology, 483 

infectiousness of, 491 

localization of lesions, 493 

pathology, 488 

prognosis, 524 

symptoms, 486 

treatment, 508 

urine in, 494 
complications, 417 
diagnostic table, 387 
endoscope in, 499 
hygiene of, 395, 484, 508 
infectious, 360 
in women, 602 
non-infectious, 369, 381, 387 
pathology, 381 
posterior acute, 417 

diagnosis, 419 

etiology, 417 

symptoms, 418 

treatment, 420 
syphilitic, 368 
tuberculosa, 368 
urine in, 494 

shreds, color-test for, 497 

two-glass method, 495 
Urethrometer, 564 

Otis's, 564 
Urethrotome, Civiale's, 590 
Maisonneuve's, 591 
Otis's, 591 
Urethrotomy, external, 593 
indications for, 587 
internal, 589 



Urinary fever, 596 
Urine in gonorrhoea, copaiba reac- 
tion^ 402 
in urethritis, two-glass test, 419 

Vagina syphilis of, 184 

Vaginitis, gonorrhoeal, 602 

Vapor for the nostrils in syphilis, 

269 
Vaporization of mercury, 244 
Vegetating syphiloderm, 131 
Vegetations with chancroid, 305 
Venereal warts, 47, loi, 342 
treatment, 343 

Verole, 27 

Verruca acuminata, 47, loi 
Vesiculitis, 448 
symptoms, 448 
treatment, 449 
Veterans of syphilis, 287 

Virulenter Bubo, 309 

Virus, syphilitic, 28 

Virus-carriers, 29 

Viscera in syphilis, treatment, 271 

Vitreous humor, syphilis of, 200 

Vulvitis, gonorrhoeal, 604 

"Wart-cure," 263 
Warts, moist, 47, loi 

pointed, 102 

venereal, 47, loi, 342 
treatment, 343 
Weicher Schanker, 293 
Wife, infected, 285 
Wilkinson's salve, 262 
Winternitz's psychrophor, 518 



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